CLINICALDERMATOLOGYA Manual of Differential DiagnosisThird Edition

By

Stanferd L. Kusch, MD

Compliments of:

www.taropharma.com

Copyright © 1979 (original edition) by Stanferd L. Kusch, MDSecond Edition 1987

Third Edition 2003

All rights reserved. No part of the contents of this bookmay be reproduced or transmitted in any form or by anymeans, including photocopying, without the written permission of the copyright owner.

NOTICEMedicine is an ever-changing science. As new research and clinicalexperience broaden our knowledge, changes in treatment and drugtherapy are required. The author and the publisher of this work havechecked with sources believed to be reliable in their efforts to pro-vide information that is complete and generally in accord with thestandards accepted at the time of publication. However, in view of thepossibility of human error or changes in medical sciences, neitherthe author nor the publisher nor any other party who has beeninvolved in the preparation or publication of this work warrants thatthe information contained herein is in every respect accurate or com-plete, and they disclaim all responsibility for any errors or omissionsor for the results obtained from use of the information contained inthis work. Readers are encouraged to confirm the information here-in with other sources. For example and in particular, readers areadvised to check the product information sheet included in the pack-age of each drug they plan to administer to be certain that the infor-mation contained in this work is accurate and that changes have notbeen made in the recommended dose or in the contraindications foradministration. This recommendation is of particular importance inconnection with new or infrequently used drugs.

To my wifeand

best friend,Linda;

and to mytwo wonderful

daughters,Kali and Amy—

they madeit all

worthwhile.

INTRODUCTION TO THE THIRD EDITION—2003

That there is a third edition of this manual is somewhat serendipitous.Judging from the numerous letters I have received over the past twen-ty odd years from dermatologists, residents, internists, and familypractitioners—all requesting either a replacement for their “worn-out” copy or information on how they could obtain a new copy—itseems that this manual has had a tremendous word-of-mouth fol-lowing, especially among dermatology residents. The original andsecond editions of this manual were distributed free of charge to allfirst year dermatology residents in the United States and Canada in the1980s and early 90s courtesy of Westwood Pharmaceuticals. AfterWestwood Pharmaceuticals was taken over by Squibb and then withfurther consolidations in the drug industry, the publication of thismanual was seemingly lost in the shuffle despite a persistent demandby more recent residents for its availability. Some of the more per-sistent residents (and dermatologists in private practice) tracked medown at my solo private practice in Bend, Oregon and requested whatfew copies I had left from the earlier printings.

Then, in July of 2003, after having sent out one of my last remainingcopies of the manual, I received an unexpected call from an attorneyfor Taro Pharmaceuticals, U.S.A., Inc. (Taro) wanting to know if I stillheld the copyright. Apparently, Dr. Jacob Levitt, a dermatology resi-dent at Mount Sinai Medical Center had consulted for Taro. He andhis fellow residents were aided by old, handed down copies of themanual, which were used during many of those infamous “unknownconferences” (where dermatology residents are randomly directed byprofessors to go to the blackboard and “list the differential diagnosis”of a lesion just seen on a patient). Thus, at his urging, you now holdin your hand, courtesy of Taro (especially Dr. Jacob Levitt, and hisfather and CEO Dr. Barrie Levitt), the newest edition of the manual—the “little book that just wouldn’t go away”.

Again, I must thank my fellow residents, Ron Wheeland, RichardHoshaw, and Gary Wright who provided input to the original edition in1979-80 and Mark Everett, the former Chairman of the Department ofDermatology at the University of Oklahoma, who encouraged me tocompile and publish my “lists”.

Stan Kusch, MDBend, OregonAugust, 2003

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INTRODUCTION TO THEORIGINAL EDITION—1979

This is a manual of differential diagnoses of clinical skin lesions. It isintended for the use of practicing dermatologists, all primary carephysicians dealing with skin problems, medical students rotatingthrough dermatology electives, and especially for new dermatologyresidents faced with the awesome task of classifying the hundreds ofcutaneous diseases into “clinical groups”.

The main question this manual seeks to answer is: “What else couldit be?”—that unsettling question that troubles all physicians, espe-cially when initial treatment is unsuccessful. This manual should alsobenefit dermatology residents during the infamous clinical confer-ences where they are asked to “list the differential diagnosis…”.

The lists are not intended to be “all inclusive” or complete. They aresimply intended to quickly bring to mind different diseases whichmay present in a similar manner, and possibly as a starting point inthe differential workup of a puzzling case.

Ample space is provided along side each entity to encourage the reader to write in specific differential points of each disease in the list, and certainly to add to each list as needed. Used in this way, the manual may be utilized as a “work book” inorganizing material to be mastered. The cross reference indexshould aid in quick location of topics. The source of the materialhas been compiled and integrated from various dermatologic text-book descriptions (Rook, et al.; Moschella, et al.; Demis, et al.;etc.), dermatologic journals (especially the Archives ofDermatology) and from input by the members of the teaching staffof the Department of Dermatology at the University of Oklahomaduring weekly clinical conferences over the last three years. A spe-cial thanks to Doctors Mark A. Everett, Dennis Weigand, and WalterBurgdorf for their helpful suggestions.

S. L. Kusch, M.D.Enid, OklahomaNovember, 1979

*5ii

I. DEFINITIONS

DEFINITIONS OF PRIMARY LESIONS

Macule—a circumscribed area of change in normal skin color without elevation or depression of the surface relative to the surrounding skin and less than 1 cm in diameter.Patch—a macule greater than 1 cm.Papule—a solid lesion, usually dome-shaped, less than 1 cm in diameter. Most is elevated above, rather than deep within, the plane of the surrounding skin.Nodule—a palpable, solid lesion deeper than a papule and in the dermis or subcutaneous tissue.Plaque—an elevation above the skin surface that occupies a relatively large surface area in comparison with its height above the skin. Frequently formed by a confluence of papules.Vesicle—a circumscribed, thin-walled, elevated lesion containing fluid. Less than 1 cm in diameter.Bulla—a vesicle greater than 1 cm in diameter.Purpura—a non-blanching, purple discoloration of the skin due to extravasation of blood into the skin. May be palpable or non-palpable.

Petechiae—purpura less than 1 cm.Ecchymosis—purpura greater than 1 cm.

Erythema—an area of uniform redness that blanches with pressure.Wheal—an evanescent, edematous plaque, usually lasting onlya few hours, with peripheral redness and usually pruritus.Telangiectasia—blanchable, small superficial dilatedcapillaries.

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II. PRIMARY LESIONS

MACULES AND PATCHESWHITE MACULES (HYPOMELANOSIS)

Lichen sclerosis et atrophicusMorpheaAtrophic lichen planusVitiligoTuberculoid leprosyPityriasis albaPost inflammatory hypopigmentationNevus anaemicusNevus depigmentosusHalo nevus without nevusTinea versicolorIdiopathic guttate hypomelanosisIncontinentia pigmenti – fourth stageHypomelanosis of ItoRadiation dermatitisSyphilis, yaws, pintaChemical (hydroxyquinones, phenols, etc.)Oculocutaneous albinismPartial albinism (piebaldism)Chediak-Higashi syndromeVogt-Koyanagi syndrome (vitiligo)Alezzandrini’s syndrome (vitiligo)Waardenburg’s syndrome (piebald)Tuberous sclerosisAmino acid disorders (e.g. PKU)Thyroid diseaseAmelanotic melanoma or melanoma with regressionScarring discoid lupus erythematosus

BROWN MACULES

Café au lait spots—von Recklinghausen’s NeurofibromatosisFanconi’s syndromeDyskeratosis congenitaAtaxia-telangiectasiaTuberous sclerosisBloom’s syndromeNormal skin (less than six)

Incontinentia pigmenti – third stageFixed drug eruptionAlbright’s syndrome

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EphelidesLentigo simplex and senilisSeborrheic keratosis (early)Becker’s nevusNevus spilusAcanthosis nigricansHemchromatosisMongolian spotACTH administrationAddison’s diseaseNevus of Ota, ItoJunctional nevusMelasmaDrug (arsenic, psoralen, chlorpromazine, minocycline, etc.)Post inflammatory hyperpigmentationMacular amyloidosisLichen amyloidosisCongenital nevusBerloque dermatitisPhytophotodermatitis (limes, celery, etc.)Erythema dyschromicum perstansMoynahan’s syndrome (LEOPARD)Lentigo malignaPeutz-Jeghers syndrome

ATROPHIC PATCHES

Atrophic lichen planusLupus erythematosusAtrophoderma of Pasini and Pierini (Elastolysis)Follicular atrophodermaLeprosyMacular atrophyAnetodermaLues, tertiaryExtramammary Paget’sLichen sclerosus et atrophicusMorpheaNecrobiosis lipoidica diabeticorumSarcoidosisSteroid application or injectionFocal dermal hypoplasiaAplasia cutis congenitaAcrodermatitis chronica atrophicansChronic graft vs. host reactionMeicher’s granuloma

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StriaeNevus lipomatosusAtrophie blanche

PAPULES AND PLAQUESPAPULES IN ANNULAR GROUPS

Granuloma annulareElastosis perforans serpiginosaErythema elevatum diutinumMeicher’s granulomaNecrobiosis lipoidica diabeticorumBasal cell carcinomaMastocytomaLymphocytic infiltrate of JessnerLymphoma/leukemia cutisLymphocytoma cutisLichen planusLeiomyomaSarcoidosisLues, secondary or tertiaryBitesContact dermatitisAlopecia mucinosa

HYPERKERATOTIC PAPULES

Darier’s diseaseFollicular lichen planusLichen spinulosusKeratosis pilarisCutaneous hornActinic keratosisKeratoacanthomaReactive perforating collagenosis (collagen fibers)Kyrle’s disease (acquired perforating dermatosis) Lithium ingestionPhrynodermaPityriasis rubra pilarisElastosis perforans serpiginosa (elastic fibers)Arsenic ingestionVerruca vulgaris/planaSeborrheic keratosis Acrokeratosis verruciformis of HopfEpidermal neviLichen striatusLocalized epidermolytic hyperkeratosis

Keratosis punctataConfluent reticulate papillomatosis (Gougerot-Carteaud)Perforating folliculitis

LICHENOID PAPULES

Lichen planus Papular granuloma annulareVerruca planaLichen nitidusLichen striatusLichen amyloidosisMolluscumSarcoidosisLichenoid drug eruptionFrictional lichenoid (in atopics)Secondary luesLichen scrofulosorumLichen sclerosus et atrophicusLichen simplex chronicusLichen spinulosusLichen ruber moniliformisLichen myxedematosusLichenoid seborrheic keratosisLichenoid actinic keratosisBowenoid papulosis (genitals)Cowden’s disease (lichenoid papules on the face)Gianotti-Crosti (acral lichenoid papules)

LINEAR PAPULES

Lichen striatusLinear verruca vulgaris or verruca planaNevus unius laterisLinear porokeratosisLichen planusLinear epidermal nevusIchthyosis hystrixNevus verrucosus Contact dermatitisHerpes zoster (usually vesicular)Granuloma annulareBites (papular urticaria)Jellyfish stings (usually vesicular)

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ACUTE GENERALIZED RED PAPULES

Bites (papular urticaria)Pityriasis lichenoides et varioliformis acutaLymphomatoid papulosisFolliculitis (bacterial, candidal, eosinophilic)Miliaria rubra/profundaScabiesGianotti-Crosti syndrome (children-acral only; hepatitis B, EBV)Eruptive xanthomasPapular drug eruptionBacteremia (meningococcal, gonococcal, etc.)Viral exanthemHot tub folliculitis (Pseudomonas)Disseminated candidiasis

ANNULAR PLAQUES

Lymphocytic infiltrate of JessnerAlopecia mucinosaErythema annulare centrifugumErysipeloidCutaneous larva migransDiscoid lupus erythematosusGranuloma annulareSeborrheic dermatitisNummular eczemaTineaDeep fungal infectionPsoriasisHerald patch of pityriasis roseaParapsoriasisMycosis fungoidesMorpheaLichen sclerosus et atrophicusSarcoidosisLeprosyLues, secondaryBasal cell carcinomaGranuloma facialeLymphocytoma cutisFixed drug eruptionBowen’s diseaseLichen planusPorokeratosis of MibelliUrticariaPapular mucinosis

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Erythema chronicum migrans (Lyme disease)Necrobiosis lipoidica diabeticorumPolymorphous light eruptionLeukemia/lymphoma cutisErythema multiformeLupus vulgarisLichen simplex chronicusFactitial dermatitis

RED PLAQUES

Bowen’s diseaseSuperficial basal cell carcinomaPsoriasisLeprosyLupus vulgarisLeishmaniasisDiscoid lupusErythema elevatum diutinumPolymorphous light eruptionRosaceaLymphocytic infiltrate of JessnerPseudolymphoma of Spiegler-FendtLeukemia/lymphoma cutisAlopecia mucinosaLangerhan’s cell histiocytosis (intertriginous areas)Acute hemorrhagic edema of infancySarcoidosisGranuloma facialeFixed drug eruptionMycosis fungoidesGranuloma annulareSeborrheic dermatitisEosinophilic granulomaActinic keratosisMalignant angioendotheliomatosisKaposi’s sarcomaSweet’s syndromeAmelanotic melanoma

NODULES AND TUMORS

DERMAL TUMORS AND NODULES

Histiocytomas

DermatofibromaDermatofibrosarcoma protuberans

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Fibrous histiocytomaSclerosing hemangiomaProgressive nodular histiocytosis

Neural

NeuromaNeurofibromaNeurilemmoma, schwannoma, neurothekeoma

Appendageal

SyringomaClear cell acanthomaChondroid syringomaTrichoepitheliomaTrichofolliculomaPilomatrixomaClear cell hidradenomaEccrine poromaTricholemmomaHydrocystomaCylindromaEccrine spiradenomaEccrine acrospiromaAdenoma sebaceumNevus sebaceousSebaceous adenoma (consider Muir-Torre syndrome)Sebaceous epithelioma (consider Muir-Torre syndrome)

Cysts

Epidermoid cystPilar (trichilemmal) cystDermoid cystSteatocystoma multiplexGanglion cystDigital mucous cystPhaeohyphomycotic cyst

Granulomas

Foreign body granulomaLupus vulgarisSarcoidosisReticulohistiocytomaSubcutaneous granuloma annulareRheumatoid noduleJuvenile xanthogranulomaInfectious granuloma (atypical mycobacteria, fungal, etc)

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VascularErythema elevatum diutinumPeriarteritis nodosumKaposi’s sarcoma (classical and HIV)AngiosarcomaHemangiopericytomaGlomus tumorAcquired tufted angiomaHemangiomaA-V malformationAngiolymphoid hyperplasia with eosinophilia

Cancer

Nodular basal/squamous cell carcinomaVarious soft tissue sarcomasNodular melanomaLeukemia/lymphoma cutisMycosis fungoidesCutaneous metastases

Other

LeiomyomaAtypical fibroxanthomaLipoma/hibernomaCalcinosis/osteoma cutisSpitz nevusErythema nodosumHypertrophic scar/keloidEruptive/tuberous xanthomaTophusBot fly and other larval encasementsSeroma/hematomaForeign body

INFLAMMATORY NODULES

Legs

Erythema nodosumErythema induratumPolyarteritis nodosaNodular vasculitisBuerger’s diseaseWeber-Christian panniculitisSubcutaneous fat necrosisEmbolic nodulesRothmann-Makai (lipogranulomatosis subcutanea)

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Superficial thrombophlebitisWegener’s granulomatosisSporotrichosisMetastatic carcinomaSarcoidosisAbcess/furuncle/carbuncle/pyodermaDeep fungusKaposi’s sarcomaTrichophyton granulomaSweet’s syndromeLeukocytoclastic vasculitisCutaneous myiasisClear cell acanthomaKeratoacanthoma/squamous cell carcinomaThrombosed varicosity

Hands

Milker’s noduleOrfCowpoxVerruca vulgarisFuruncle/abscessPrimary tuberculosisAtypical mycobacteriaTularemiaAnthraxDeep fungal infection (sporotrichosis, blastomycosis, etc.)Giant molluscumNodular basal/squamous cell carcinomaKeratoacanthomaForeign body granulomaDigital fibrokeratomaHypertrophic actinic keratosisDigital mucous cystGottron’s papules (dermatomyositis)Rheumatoid noduleCalcinosis cutis (consider CREST)Cutaneous myiasis (bot fly encasements, etc.)Early pyoderma gangrenosumSweet’s syndrome

RED NODULES

Vascular

Angiokeratoma (consider Fabry’s disease)Angiosarcoma

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HemangiopericytomaHemangiomaKaposi’s sarcomaPyogenic granulomaA-V malformationLeukocytoclastic vasculitisCutaneous polyarteritis nodosa (especially wrists and ankles)

Histiocytic

SarcoidosisForeign body granulomaEosinophilic granulomaAtypical fibroxanthomaEruptive xanthomaDermatofibromaDermatofibrosarcoma protuberansNodular granuloma annulare

Inflammatory

BitesSweet’s syndromeErythema nodosumErythema induratumWeber-Christian panniculitis

Infectious

TularemiaLeishmaniasisAnthraxOrfMilker’s noduleAtypical mycobacteriaBacterial abscess, furuncleNodular scabies

Cancer

Basal/squamous cell carcinomaLeukemia cutisLymphoma cutisCutaneous endometriosisMetastatic carcinomaKeratoacanthoma

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Miscellaneous

Appendage tumors (clear cell acanthoma, clear cellhidradenoma, eccrine poroma, etc.)

LeiomyomaBenign juvenile melanoma (Spitz nevus)Cutaneous myiasisNeurothekeomaLymphomatoid papulosis

INFECTIOUS ASCENDING NODULES(Sporotrichoid lesions)

SporotrichosisCat scratch diseaseTularemiaAtypical mycobacteriaBacterial lymphangitisPrimary inoculation blastomycosisPrimary inoculation tuberculosisMelioidosisGlandersSodukuNocardiaLeishmaniasisLepromatous leprosy

SUBCUTANEOUS NODULES WITHOUT EPIDERMAL CHANGES

Sarcomas

AngiosarcomaLeiomyosarcomaFibrosarcomaMalignant fibrous histiocytomaLiposarcoma

Histiocytomas

Sclerosing hemangiomaDermatofibromaFibrous histiocytomaDermatofibrosarcoma protuberans

Neural

NeurofibromaNeuromaNeurolemmoma, schwannoma, neurothekeoma

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Appendageal

Spiradenoma, hidrocystoma, acrospiroma, mixed tumor, pilartumors, etc.

Cysts

Epidermoid—(if multiple, R/O Gardner’s syndrome)True epidermal (post traumatic)Pilar (trichilemmal)MucousGanglionEccrine hidrocystomaSteatocystoma multiplexSeromaEmbryologic (branchial cleft, thyroglossal duct cyst)

Calcified

PilomatrixomaPrimary and metastatic calcificationCalcified epidermoid and pilar cystsCalcinosis cutis (consider CREST)Osteoma cutis

Other

Thrombosed varicositySubcutaneous granuloma annulareErythema elevatum diutinumRheumatoid noduleSynovial tumorGouty tophiGlanders (“Farcy buds”)LeiomyomaLipomaAngiolipomaMetastatic cancerForeign body granulomaNodular pseudosarcomatous fasciitisCutaneous myiasis

SUBCUTANEOUS CORDS

Collagen nevusSuperficial thrombophlebitisMondor’s diseasePanniculitis (traumatic or inflammatory)Thrombosed varicosityIntravenous drug abuse

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PAINFUL TUMORS

Glomus tumorNeuromaEccrine spiradenomaLeiomyomaNeurilemmomaAngiolipomaBlue rubber bleb nevusCutaneous endometriosisOsteoma cutisChondrodermatitis nodularis helicisForeign body granulomaAdiposis dolorosa (Dercum’s disease)

PUSTULES, VESICLES AND BULLAE

PUSTULAR ERUPTIONS

Acne vulgarisPustular psoriasisImpetigo herpetiformisMiliariaImpetigoSteroid acneFolliculitis (bacterial, candidal, eosinophilic, fungal, steroid use)Sycosis barbaeTinea (especially with topical steroid use)Furuncle, carbuncle (early)Bockhart’s impetigoEcthymaIntertrigoLithium folliculitisHerpes simplex/zosterHot tub folliculitis (Pseudomonas)PerlecheCellulitisErysipeloidAnthraxDeep fungal infections (sporotrichosis, actinomycosis, Nocardia, etc.)RhinoscleromaAtypical mycobacteriaErythema toxicum neonatorumMiliaria rubraTransient neonatal pustular melanosisScabiesMultiple arthropod bites

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CowpoxMonkeypoxInfected contact dermatitisDisseminated candidiasisAcute febrile neutrophilic dermatosisVaricellaSmallpoxPemphigus foliaceus, IgA pemphigusSubcorneal pustular dermatosis (Sneddon-Wilkinson)Hailey-Hailey diseaseDermatitis herpetiformisGonococcemiaInfected dyshidrotic eczemaPustular bacterid

VESICLES AND BULLAE (see also VESICULO—PUSTULES IN THE NEWBORN)

Face

Hydroa aestivalePolymorphous light eruptionErythema multiforme bullosaBullous fixed drug eruptionBullous lichen planusUrticaria pigmentosaDermatitis herpetiformisBullous pemphigoidPorphyria cutanea tardaPemphigus vulgaris, foliaceus, IgA pemphigusBenign mucous membrane pemphigoidBehçet’s syndromeBullous impetigoHerpes simplex/zosterVaricellaSmallpoxContact dermatitisBitesFactitial dermatitisToxic epidermal necrolysis (and Stevens-Johnson)Burn, second degreeMiliaria crystalline

TrunkErythema multiforme major Bullous pemphigoid

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Bullous lichen planusDermatitis herpetiformisBullous fixed drug eruptionBenign familial pemphigus (Hailey-Hailey disease)Pemphigus vulgaris, foliaceus, IgA pemphigus Toxic epidermal necrolysis (and Stevens-Johnson)Staph scalded skin syndromeAutolysis (coma, impending demise)Pyoderma gangrenosumUrticaria pigmentosa/mastocytomaErythema elevatum diutinumIncontinentia pigmenti—first stageGunther’s diseaseTinea corporisBullous impetigoViral infection (simplex, zoster, varicella, smallpox)ScabiesBitesContact dermatitisFactitialBurn, second degreeHerpes gestationis (if pregnant)Transient acantholytic dermatosis (Grover’s disease)Vesicular idMiliariaLymphangioma/seromaPressure urticariaSubcorneal pustular dermatosis (Sneddon-Wilkinson)Chronic bullous dermatosis of childhoodCongenital ichthyosiform erythrodermaNecrolytic migratory erythema (glucagonoma)Bullosa diabeticorumRickettsialpox

Hands and feet

Porphyria cutanea tardaPseudoporphyria (NSAIDs)HemodialysisPolymorphous light eruptionDiscoid lupus erythematosusErythema multiformeBullous lichen planusBullous fixed drug eruptionEpidermolysis bullosa

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Weber-Cockayne syndromePhotoallergic drug eruptionHand, foot, and mouth diseaseHydroa vacciniformeBullous pemphigoidTinea manum/pedisErythema elevatum diutinumFactitialAutolysis (pressure, impending demise)Cat scratch diseaseNecrolytic migratory erythema (glucagonoma)Drug reaction (carbon monoxide, phenobarbital, nalidixic acid,

cantherone)Sweet’s syndromeScabiesBitesContact dermatitisHerpes simplex/zosterDyshidrotic eczema (pompholyx)Burn, second degreeVesicular idFriction blisterBullous impetigoToxic epidermal necrolysisBullosa diabeticorum

Hemorrhagic Vesicles and Bullae

Smallpox (variola)Herpes simplex/zosterGonococcemia, meningococcemiaErythema multiforme (rare)

VASCULAR LESIONSTELANGIECTASIA

Primary

Essential telangiectasiaHereditary hemorrhagic telangiectasia

(Osler-Weber-Rendu)Ataxia telangiectasiaNevus telangiectaticusTelangiectasia macularis eruptiva perstansPoikilodermatous diseases—

Poikiloderma atrophicans vasculare

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Bloom’s syndromeRothmund-Thomson syndromeCockayne’s syndromeDyskeratosis congenitaXeroderma pigmentosum

Secondary

RosaceaPregnancyCollagen vascular diseaseLiver diseaseDrugs (estrogen, corticosteroids)Radiation dermatitisChronic topical steroid applicationActinic damageKeloidNecrobiosis lipoidicaBasal cell carcinomaPoikiloderma of Civatte

ERYTHEMA

Toxic erythema (drug, infection, systemic disease)Figurate erythemas—

Erythema multiformeErythema annulare centrifugumErythema marginatumErythema chronica migransErythema gyratum repensErythema dyschromicum perstans

Urticaria pigmentosaUrticariaFixed drug eruptionVascular neviPhysical agents—

Heat (erythema ab igne, first degree burn)ColdTrauma

Scarlet fever CarcinoidUltraviolet exposureErysipelasStaph/strep toxic shock syndromeNecrolytic migratory erythema (glucagonoma)Acral erythema (palms and soles—due to chemotherapy)

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Viral exanthems—enterovirus, hepatitis, mononucleosis, measles,roseola, erythema infectiosum, etc.

Drug hypersensitivity syndrome (sulfa, anticonvulsants, allopurinol, minocycline, etc.)

PALPABLE PURPURA(Cutaneous vasculitis)

I. Cutaneous and systemic—usually leukocytoclastic unless noted

Drug (usually lymphocytic)—ASA, NSAIDs, sulfa, chloroquine, penicillin, quinidine, thiazides, TB drugs, phenothiazines, etc.Infection—strep, RMSF, GC, meningiococcemia, TB, syphilis, viruses (especially hepatitis, etc.)Collagen vascular diseases (usually a livedo pattern)—rheumatoid arthritis, SLE, dermatomyositis, Sjörgen’s , inflammatory bowel disease, etc.Carcinoma—lymphoma, leukemia, lung and bowel cancer, Hodgkin’s disease, multiple myeloma, etc.Abnormalities in blood viscosity—

Cryoglobulinemia—cold exposure, multiple myeloma, SBE, leukemia, RA, liver disease, hepatitis, disseminated cancer, syphilis, mononucleosis, primary idiopathic, etc.Cryofibrinogens—abnormality in clotting and degredation—seen in viral diseases (especially hepatitis)Cold agglutinins—viral pneumonia, SLE, lymphomaHypergammaglobulinemic purpura

Other—Henoch-Schöenlein purpura—abdominal pain, mucosal bleeding, hematuria, arthralgias, headachePolyarteritis nodosa and other related granulomatous

arteritides—allergic granulomatosis, Wegener’s, etc.

II. Mainly cutaneous

Hypersensitivity vasculitis/idiopathic allergic vasculitis/anaphylactoid purpura (all likely the same entity)—usually due to infection, drug, or systemic disease.Pityriasis lichenoides et varioliformis acuta (PLEVA)

(This is lymphocytic as opposed to leukocytoclastic.)Erythema elevatum diutinumSweet’s syndromeUrticarial vasculitis/erythema multiformeCutaneous polyarteritis nodosa

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NON-PALPABLE PURPURA (Petechial and Ecchymotic)

Coagulopathies—DIC, liver disease, anticoagulant therapyThrombocytopenia—ITP, TTP, bone marrow depression, etc.Thrombocythemia—platelets greater than 1,000,000Scurvy—usually perifollicularDrug—anticoagulants, phenacetin, steroids, carbromal, NSAIDsSystemic disease—diabetes, Cushing’s disease, uremia, etc.Senile purpura (increased skin fragility)Infections—SBE, RMSF (usually palpable), meningococcemia,

gonococcemia, Weil’s disease (leptospirosis), various hemor-rhagic fevers including Ebola and Marburg, congenital rubella,echovirus, toxoplasmosis, cytomegalovirus, etc.

Livedo reticularisTraumatic purpuraResolving erythemas (see differential of “Erythema”)Toxic venomsWaldenström’s hyperglobulinemic purpuraHypersensitivity vasculitisPurpuric oddities (capillaritis)—

Schamberg’s purpura—“cayenne pepper” pattern on legsMajocchi’s purpura (purpura annularis telangiectoides)Gougerot-Blum—purpuric lichenoid dermatitisDucas and Kapetanakis—eczematoid purpura

ULCERS AND NECROSISULCERS

TraumaticFactitial (psychocutaneous)—neurotic excoriations, delusions

of parasitosisBurnsCirculatory disorders—

ArteriosclerosisThromboangiitisStasisDecubitus (pressure)Vasculitic (see differential of “Vasculitis”)Hypertensive Thrombosed varicosity

Blood element pathology—Sickle cell ulcerCongenital hemolytic anemiaPolycythemiaCold agglutinins

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Bacterial—SyphilisYawsEcthymaTuberculosis and atypical mycobacteriaScrofulodermaGranuloma inguinaleAnthraxTularemiaCutaneous diphtheriaGlandersMelioidosisPhagedenic ulcerLeprosyChancroid

Deep fungal—Sporotrichosis, blastomycosis, histoplasmosis, candida,coccidioidomycosis, actinomycosis, chromoblastomycosis

Parasitic—Leishmaniasis, amebiasis

Malignancy—Basal cell, squamous cell, melanoma, mycosis fungoides, metastases, lymphoproliferative malignancies

Bites—Brown recluse spider, etc.Miscellaneous—

Antiphospholipid syndromeCrohn’s diseaseNecrobiosis lipoidica diabeticorumPyoderma gangrenosumRadiation dermatitisIntravenous drug abuse

ULCEROGLANDULAR DISEASES(Ulcers with lymphadenitis)

Bubonic plagueLymphogranuloma venereumStreptococcal/staphylococcal adenitisChancroidSyphilisPrimary inoculation tuberculosis/atypical mycobacteriumCat scratch diseaseTularemia

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BrucellaAnimal bite (Pasteurella multocida)Rat bite fever (Spirillum minus)MelioidosisGlandersAnthraxSporotrichosis

NECROTIC LESIONS*

Anemic or ischemic infarction

Vasospastic—Raynaud’s, hypertensive ulcer, ergot poisoning, arterial or venous drug extravasation

Embolization—atheromata, thrombus, fat, etc.Primary vascular—arteriosclerosis, thromboangiitis,

diabetes, etc.Vasculitis secondary to connective tissue disease—SLE,

polyarteritis, rheumatoid arthritis, temporal arteritis,Wegener’s, CREST, etc.

Dysproteinemias—cryoglobulins, cryofibrinogensDisseminated intravascular coagulationPhysical agents—heat, cold, trauma, pressure, electrical,

radiation, etc.Chemical agents—coumadin, I.V. adrenergics, chemothera-

peutic agentsCalciphylaxisEnvenomation—brown recluse spider, snakes, scorpion, etc.Factitial

Microbiological agents

Bacterial—anthrax, diphtheria, streptococcus,Pseudomonas, atypical mycobacteria, meningococcus, etc.

Viral—smallpox, herpes zosterTreponemes—syphilis, yaws, bejel, etc.Rickettsial—RMSF, typhus, etc.Protozoan—amebiasis, schistosomiasis, etc.Fungal—Nocardia, actinomycosis, sporotrichosis,

histoplasmosis, Cryptococcus, blastomycosis

Inflammatory

Pyoderma gangrenosum

*After Samuel L. Moschella, Dermatology, Vol. 1, Moschella, Pillsbury, and Hurley; p. 896, W.B. Saunders, 1975

23

24

III. MORPHOLOGIC GROUPS

ECZEMA (DERMATITIS)

Contact dermatitis (primary irritant, allergic)Dyshidrotic eczema (pompholyx)Atopic dermatitisNeurodermatitisPhotoallergic dermatitisNummular eczemaAsteatotic eczemaSeborrheic dermatitisInfectious eczematoid dermatitisLichen simplex chronicusDrug reactionEczematous eruptions associated with systemic disease—

Wiskott-AldrichX-linked agammaglobulinemiaPhenylketonuriaAhistidinemiaHurler’s syndromeHartnup’s diseaseAcrodermatitis enteropathicaNetherton’s syndrome

PAPULOSQUAMOUS DISEASES

PsoriasisSeborrheic dermatitisErythema annulare centrifugumLichenoid eruptions (lichen planus, lichen striatus, etc.)Pityriasis roseaDermatophyte infectionsSyphilis, secondaryDrug eruptionsParapsoriasis groupPityriasis rubra pilarisDiscoid lupus erythematosusEczema (see differential of “Eczema (Dermatitis)”)Contact dermatitis (primary irritant, allergic)Pityriasis lichenoides chronicaTinea versicolorIchthyosis groupEczematous eruptions associated with systemic disease

(see differential of “Eczema (Dermatitis)”)

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VERRUCOUS LESIONS

Darier’s diseaseVerruca vulgarisCondyloma acuminatumWarty dyskeratomaNevus verrucosusIchthyosis hystrixTuberculosis verrucosa cutisEpidermodysplasia verruciformisSyringocystadenoma papilliferumNevus sebaceus of JadassohnPrurigo nodularisLichen simplex chronicusKyrle’s diseaseIchthyosis linearis circumflexaVerrucous carcinomaDermatosis papulosa nigraSeborrheic keratosisLocalized congenital ichthyosiform erythrodermaLinear epidermal nevus/ILVENLichen striatusAcanthosis nigricansConfluent and reticulated papillomatosis of Gougerot and CarteaudBlastomycosis and other deep fungiBlastomycosis-like pyodermaChromoblastomycosisHalogenodermaPachyonychia congenitaIncontinentia pigmenti—second stageRupial psoriasisNorwegian scabiesPalmar and plantar keratodermaBowenoid papulosis of the genitals

HYPERKERATOSIS

Generalized

Ichthyosis—Epidermolytic hyperkeratosis (BCIE)Lamellar ichthyosisX-linked ichthyosisIchthyosis vulgarisAcquired ichthyosis—

Drug—clofibrate, nicotinic acid, etc.

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Systemic disease—Hodgkins, leukemia, visceral cancer, leprosy, sarcoid, thyroid diseaseSyndromal—

Rud’s syndromeNetherton’s syndromeRefsum’s syndromeSjögren-Larsson syndrome

Ichthyosis linearis circumflexaErythrokeratodermia variabilisDarier’s diseasePityriasis rubra pilarisPsoriasisAtopic dermatitisSézary’s syndromeMycosis fungoidesExfoliative erythrodermaXerosis

Palms and soles

Dyskeratosis congenitaHidrotic ectodermal dysplasiaNorwegian scabiesPityriasis rubra pilarisBowen’s diseasePapillon-Lefèvre syndromePachyonychia congenitaAcrodermatitis continuaClavusMal de MeledaUnna-Thost syndromeKeratosis palmaris et plantarisPunctate keratodermaConfluent verruca vulgarisLamellar ichthyosisCongenital ichthyosiform erythrodermaSjögren-Larsson syndromeTineaChronic arsenical ingestion/exposureReiter’s syndromePsoriasisChronic dyshidrotic eczemaPitted keratolysisKeratoderma climactericum

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Hyperkeratotic plaques

Lichen simplex chronicusSeborrheic keratosisBowen’s disease/superficial squamous cellActinic keratosisHypertrophic lichen planusPrurigo nodularisDeep fungal infection (sporotrichosis, blastomycosis, etc.)PorokeratosisDarier’s diseaseVerrucous carcinomaNorwegian scabiesEpidermal neviLocalized epidermolytic hyperkeratosis Ichthyosis hystrixAcanthosis nigricansConfluent and reticulated papillomatosis of Gougerot

and CarteaudFlegel’s disease (hyperkeratosis lenticularis perstans)PsoriasisPityriasis rubra pilarisTinea corporisChronic stasis dermatitisPityriasis lichenoides chronicaPityriasis roseaParapsoriasis groupIchthyosis linearis circumflexaErythrokeratodermia variabilis

DESQUAMATION (EXFOLIATION)

FeverViral exanthemToxic erythemaSystemic drugs (INH, retinoids, etc.)Sun burn, thermal burnScarlet feverToxic epidermal necrolysisExfoliative erythroderma (See differential of “Erythrodermas”)Epidermolytic hyperkeratosis (BCIE)Stevens-Johnson syndromeKawasaki’s diseaseIchthyosis (see differential of “Hyperkeratosis”)Normal desquamation of newbornKeratolysis exfoliativa (palms and soles)Chemical/topical drug (retinoids, benzoyl peroxide, salicylic acid, etc.)

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Staphylococcal scalded skin syndromeStaph/strep toxic shock syndromeOccult or metastatic diseaseLeiner’s diseaseDrug hypersensitivity syndrome

ERYTHRODERMAS

Children

Congenital ichthyosiform erythrodermaStaphylococcal scalded skin syndromeToxic epidermal necrolysisSclerema neonatorumScarlet feverImmersion burnPsoriasisAcute ultraviolet light exposureAtopic dermatitisDrug hypersensitivity syndromeToxic shock syndrome (staph/strep)Leiner’s diseaseViral exanthem

Adults

Exfoliative dermatitis secondary to—PsoriasisAtopic dermatitisSeborrheic dermatitis (especially HIV)Sézary’s syndromeLymphoma, leukemia, mycosis fungoidesPityriasis rubra pilarisDermatomyositisContact dermatitisDrug reaction (gold, quinidine, captopril, ASA,

IVP dye, sulfa, phenytoin, penicillin, etc.)Drug hypersensitivity syndrome (minocycline, sulfa, anticonvulsants, etc.) (multiple organ failure)“Red man syndrome” due to vancomycinOccult malignancy (especially lung/colon)Graft vs. host reactionTrichloroethylene toxicityPemphigus foliaceusPhotosensitivity/phototoxic reactions (doxycycline,

thiazides, etc.)Multiple myeloma

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ACNEIFORM LESIONS

Acne vulgarisRosaceaSteroid acneAcne conglobata/nodulo-cystic acneHalogenodermas (iodides, bromides)Acne medicamentosa (lithium, kelp, progesterone, etc.)Acne varioliformisChloracneAcne cosmeticaOil acneLupus miliaris disseminatus facieiPyoderma faciale/acne fulminans/rosacea fulminansPerioral papular dermatitisBacterial folliculitisSyphilis, secondaryNevus comedonicusFollicular retention cystsAcne keloidalis nuchaeTrichostasis spinulosaDemocidiosis (Demodex folliculitis)Hot tub folliculitis (Pseudomonas)Infected epidermoid cystSycosis barbaeKerion

SERPIGINOUS LESIONS

Tinea corporisSyphilis, secondary and tertiaryCutaneous larva migransGranuloma annulareElastosis perforans serpiginosaPorokeratosisUrticariaParapsoriasis variegataIchthyosis linearis circumflexaErythrokeratodermia variabilisIncontinentia pigmentiErythema gyratum repensIchthyosis hystrixEpidermal neviErythema ab ignePhytophotodermatitisContact dermatitis

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Marine organism stings (jellyfish)Factitial dermatitis

MORBILLIFORM ERUPTIONS

Rubeola (measles)RubellaAcute HIV infectionRocky Mountain spotted feverDrug eruption (especially ampicillin)DengueAcute hepatitisMeningococcemiaSyphilis, secondaryToxoplasmosisRoseolaOther viral exanthems (especially ECHO, Coxackie, etc.)Relapsing feverScarlet feverErythema infectiosum (Fifth disease)TyphusPapular pityriasis roseaGraft vs. host reactionAngioimmunoblastic lymphadenopathyKawasaki’s disease

ALOPECIA: NON-SCARRING

Alopecia areataTrichotillomaniaTraction alopeciaTelogen effluvium (physical /emotional stress, childbirth, general anesthesia, anemia, rapid weight loss, fever, SLE, etc.)Syphilis, secondaryEndocrine disorders—thyroid disorders, polycystic ovarian disease, testosterone/progesterone excess, etc.)Drug induced—oral contraceptives, Depo-Provera, propranolol, ACE inhibitors, anticoagulants, statins, retinoids, etc.Chemotherapeutic agentsCongenitalFamilial androgenic alopeciaSevere scalp dermatitis (psoriasis, seborrhea, etc.)Severe dermatophyte infectionsHair shaft abnormalitiesSyndromal—progeria, anhidrotic ectodermal dysplasia, Rothmund-Thompson, Sézary’s syndrome, etc.

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Dietary—vegans, zinc deficiency, anorexia, bulimia, etc.Loose anagen syndromeAbnormalities in iron metabolism (esp. iron-deficiency anemia)

ALOPECIA: SCARRING

Morphea (localized scleroderma)Discoid lupusPseudopeladeRadiation exposureBurnsKerionLupus vulgarisLichen planopilarisFolliculitis decalvansAplasia cutis congenitaAlopecia mucinosaAcne keloidalis nuchaeHerpes zosterTraumaDissecting cellulitis of the scalpBasal cell carcinomaScalp metastasesFactitial

SCARRING LESIONS

Cutaneous lupus (discoid)Morpheaform basal cell carcinomaAtrophic lichen planusLichen planopilarisTertiary syphilisSarcoidosisAtypical mycobacteria infectionsLupus vulgarisLupus miliaris disseminata facieiDeep fungal infectionsLichen sclerosis et atrophicusLeishmaniasisPorphyria cutanea tardaHerpes zoster/varicellaBrown recluse spider bite and other envenomationsThermal injuryAcne keloidalis nuchaeAcne conglobata/acne fulminans/nodulocystic acneChloracneHidradenitis suppurativa

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Epidermolysis bullosa dystrophicaBenign mucous membrane pemphigoidKerionDissecting cellulitisFolliculitis decalvansMorphea (coup de sabre)Lymphogranuloma venereumRadiation dermatitisExtramammary Paget’s diseaseInflammatory carcinoma of the breastAinhum

SCLEROTIC LESIONS(Sclerosis)

Morphea (localized scleroderma)Necrobiosis lipoidica diabeticorumPanniculitis group and lupus profundusMondor’s diseaseInflammatory carcinoma of the breastCutaneous metastasesLichen sclerosis et atrophicus/kraurosis vulvaeNephrogenic fibrosing dermopathy (hemodialysis or renal

transplant patients)Chronic stasis dermatitisPretibial myxedemaCutaneous amyloidosisLymphostasis verrucosumChronic illicit drug injectionScleredemaSclero-dermatomyositis, CRESTRaynaud’s syndromeChronic graft vs. host reactionWerner’s syndromeCalcinosis cutisBurn scars

LESIONS OCCURRING IN SCARS(Koebnerizing lesions)

Squamous cell and basal cell carcinomaLichen planusPsoriasisPityriasis rubra pilarisSarcoidosisVerruca vulgaris and verruca planaXanthomas

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AmyloidosisCutaneous endometriosusMiliaLichen nitidusMolluscum contagiosum (in fresh scratches)

DRAINING GRANULOMATOUS LESIONS

Madura footMycetomaProtothecosisChromoblastomycosisCutaneous myiasisPanniculitis groupLymphostasis verrucosumScrofuloderma

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IV. REGIONAL GROUPS

COMMON SCALP LESIONS

Actinic keratosisNevus sebaceus of JadassohnSyringocystadenoma papilliferumNevus verrucosusVerruca vulgarisLymphocytic infiltrate of JessnerSeborrheic dermatitisSeborrheic keratosisTinea capitisNeviBasal/squamous cell carcinomaBenign juvenile melanoma (Spitz nevus)NevoxanthoendotheliomaMastocytomaMetastasesKeratoacanthomaEpidermoid cystPilar (tricholemmal) cystCylindromaMeningiomaMelanomaAplasia cutis congenitaPsoriasisScarring alopecias (see differential of “Alopecia: Scarring”)KerionAtypical fibroxanthomaDermatofibromaDiscoid lupusPrurigo nodularisAngiosarcomaHemangiomaLentigo malignaContact dermatitisLichen planopilarisPediculosisNeurotic excoriationsFolliculitis (bacterial, fungal, candidal)Herpes zoster, varicellaArteriovenous shunts/malformations

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PAPULES ON THE FACE

Yellow to white

XanthomasXanthelasmaSebaceus adenoma (consider Muir-Torre if multiple)Senile sebaceous hyperplasiaMiliaSyringomaSpitz nevusJuvenile xanthogranulomaLupus vulgarisNevus sebaceus of JadassohnAmyloidosisMolluscum contagiosumClosed comedonePseudoxanthoma elasticum

Red to blue

Acne vulgarisHydrocystomas (apocrine and eccrine)PilomatrixomaEccrine spiradenoma and poromaGranuloma facialeLichen planusLeukemia/lymphoma cutisLymphocytic infiltrate of JessnerSyphilisAlopecia mucinosaMycosis fungoidesUrticaria pigmentosa/mastocytomaPapular urticaria/cholinergic urticariaPapular mucinosisLymphocytoma cutisAngiokeratomaPyogenic granulomaHemangiomaKimura’s disease AngiosarcomaSarcoidosisSystemic lupus erythematosusPolymorphous light eruptionRosacea and granulomatous rosaceaFixed drug eruptionFibrous histiocytoma

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Blue nevusSpitz nevusJuvenile xanthogranulomaAcne cyst/nodulePigmented basal cell carcinomaAmelanotic melanomaPerioral papular dermatitisSteroid acneDemocidiosis (Demodex folliculitis)Venous lakeKaposi’s sarcoma

Flesh colored

SyringomaTrichoepitheliomaNeviAdenoma sebaceumSenile sebaceous hyperplasiaCowden’s disease (multiple hamartoma syndrome)Sebaceous adenoma (consider Muir-Torre if multiple)NeurofibromaTrichofolliculomaBasal cell carcinomaJuvenile xanthogranulomaCylindromaPilomatrixomaEpidermoid cystMolluscum contagiosumNevus sebaceus of JadassohnVerruca planaLepromatous leprosyPapular granuloma annulareAmyloidosisFibrous histiocytomaKeloid/hypertrophic scarLupus miliaris disseminatus faceiiAmelanotic melanomaCryptococcus (HIV)Fibrous papule of the nose

Brown

Dermatosis papulosa nigraGranuloma facialeSarcoidosisNevi

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Pigmented basal cell carcinomaSeborrheic keratosisEccrine hydrocystomaDermatofibromaMelanomaAngiolymphoid hyperplasia (usually postauricular)Darier’s disease

LUPUS-LIKE LESIONS OF THE FACE(Erythema, papules, telangiectasia, atrophy)

Systemic lupus erythematosusCutaneous lupus (discoid)Polymorphous light eruptionFixed drug eruptionPhototoxic/photoallergic reactionTelangiectasia macularis eruptiva perstansInflammatory seborrheic dermatitisContact dermatitisDermatomyositisSteroid acne/atrophyPemphigus erythematosus and foliaceusErythrose peribuccale of BrocqPerioral papular dermatitisLymphocytic infiltrate of JessnerRosacea and granulomatous rosaceaGranuloma facialeSclerodermaDiffuse actinic damage (no papules)Essential telangiectasia (no papules)Democidiosis (Demodex folliculitis)Carcinoid (no papules)Iododerma/bromodermaLupus vulgarisSyndromes—Dowling-Degos, Haber’s syndrome

DESTRUCTIVE MIDLINE LESIONS OF THE FACE

Lethal midline granuloma group—Midline malignant reticulosisWegener’s granulomatosusReticulum cell sarcoma (malignant lymphoma)

SyphilisYaws/bejelLupus vulgarisLeprosy

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Sarcoidosis Mucocutaneous leishmaniasisRhinosporidiosisSouth American blastomycosisPhycomycosis (e.g. Mucor, others)Necrotizing fasciitisNomaRhinoscleromaBasal cell carcinomaKeratoacanthoma

LIP LESIONS

Leukoplakia (benign/premalignant)Fordyce spots (upper lip)Verruca/condylomaActinic cheilitisSquamous cell carcinomaVenous lakeHemangiomaLentigo (multiple--rule out Peutz-Jegher’s syndrome)Labial melanotic maculeMelanomaHerpes simplexIrritant cheilitis (lip lickers, wind burn)Allergic contact dermatitisAngioedemaMucous cystMelkerson-Rosenthal syndrome/Miecher’s granulomaCheilitis glandularis (lower lip)

LESIONS OF THE ORAL MUCOSA

Oral vesicles and bullae

Dermatitis herpetiformis/linear IgA diseasePemphigus vulgaris/pemphigus vegetansBenign mucous membrane pemphigoidErythema multiforme/Stevens-Johnson syndromeBullous pemphigoidEpidermolysis bullosaHand, foot, and mouth diseaseHerpanginaBehçet’s syndromeHerpes simplexHistoplasmosis

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Contact dermatitisMucous cyst

Oral ulcers

ApthaeCrohn’s diseaseMethotrexate reactionLeukemic agranulocytosisVincent’s anginaErosive lichen planusSyphilis (primary), GC, TB, noma, tularemiaSquamous cell carcinomaParaneoplastic pemphigusSystemic lupus erythematosusAny of the above oral vesiculo-bullous diseases after rupture

White lesions in the mouth

LeukokeratosisLeukoplakiaPsoriasisCandidaLichen planusHistoplasmosisSyphilis—secondaryHereditary benign intraepithelial dyskeratosisDarier’s diseaseWhite sponge nevusOral florid papillomatosisMorsicatio buccarum (traumatic)Pachyonychia congenitaOral hairy leukoplakia (HIV)

Papules and plaques in the mouth

Pyostomatitis vegetans (often pustular; seen with inflammatory bowel disease)Condyloma accuminatumLichen planusPsoriasisTraumaFordyce’s spotsWhite sponge nevusBowen’s diseaseSquamous cell carcinomaHereditary benign intraepithelial dyskeratosis

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Darier’s diseaseDiscoid lupusVerrucous carcinomaBenign mucosal fibromasHemangioma/lymphangiomaMucoceleCowden’s syndrome (smooth, white cobblestone)Kaposi’s sarcoma (HIV)MelanomaLeukemia (usually gingival hyperplasia, esp. AML)

TONGUE LESIONS

Smooth tongue (anemia, vitamin deficiencies)Black hairy tongueScrotal tongueGeographic tongue (benign migratory glossitis)PsoriasisCandidaHistoplasmosisMedial rhomboid glossitisLichen planusAmyloidosisBeefy red tongueBenign papillomasVerruca/condylomaLeukoplakiaBowen’s diseaseSquamous cell carcinomaMetastatic carcinomaHerpes simplexSyphilis—primary chancre, condyloma latumHemangiomaCrohn’s diseaseAphthous ulcersTraumatic lesionsPhlebectasiaHeterotopic lingual tonsilOral hairy leukoplakia (HIV)Polyarteritis nodosa (ulcers and necrosis)Multiple mucosal neuromas (MEN IIb syndrome)Lipoid proteinosis

PIGMENTED AXILLARY LESIONS

Acanthosis nigricansFox-Fordyce disease

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Contact dermatitisHidradenitis suppuritiva/furunculosisHailey-Hailey diseaseChromhidrosisErythrasmaTineaTrichomycosis axillarisPost inflammatory hyperpigmentationCrowe’s sign (von Recklinghausen’s disease)Hyalinosis cutis et mucosaeEpidermal neviOchronosisPseudoacanthosis nigricans (obesity)Multiple acrochordonsCandidiasisStriaePseudoxanthoma elasticumLangerhan’s cell histiocytosis

PUSTULES OF THE PALMS AND SOLES

Dyshidrotic eczema (pompholyx)Acrodermatitis continuaDermatitis climactericumPustular psoriasisPustular bacteridPustulosis plantaris et palmarisTinea manum and pedisReiter’s diseaseInfectious eczematoid dermatitisMonkeypoxOrfMilker’s noduleScabiesAcropustulosis of infancy (usually in black males)Hand, foot, and mouth diseaseVaricella/smallpox

PURPURIC LESIONS OF THE PALMS AND SOLES

Rocky mountain spotted feverSecondary syphilisErythema multiformeSmallpox (also vesicular)Hand, foot, and mouth disease (also vesicular)

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NAIL CHANGES AND DYSTROPHIES

Color changes

Yellow—lymphedema, nicotine stains, onychomycosisOrange-brown—nail hardeners (formaldehyde), mercury

containing creams, hemochromatosis, Addison’s disease,hyperthyroidism, hydroxyquinone containing creams, etc

Blue—Wilson’s disease, cyanosis/COPDGray-brown—tetracycline, minocycline, argyriaWhite—Terry’s nails (cirrhosis)Green—Pseudomonas infectionBlack—hemorrhage, melanomaSalmon to orange—psoriasis, acrylic glue (false nails)Half and half nails—renal diseaseWhite bands—arsenic (Mee’s lines), systemic stress, etc.

Acquired dystrophies—(usually due to disease in the matrix)Trauma to matrixParonychiaFurrowing secondary to digital mucous cystEczema in matrixTumorsFungal dystrophyDarier’s disease (white longitudinal streaks)Lichen planus (longitudinal ridges, pterygium)Twenty-nail dystrophy (trachyonychia)Pitting—psoriasis, alopecia areata, Darier’s diseaseKoilonychia (spoon nails)—iron deficiencyMedian nail dystrophy (midline canal)Pincer nails

Congenital dystrophies

LeukonychiaNail-patella syndromePachyonychia congenitaCongenital ectodermal dysplasiaEpidermolysis bullosaDyskeratosis congenita

Onycholysis

Psoriasis, fungal disease, trauma, thyroid disease, factitial,acrylic glue (false nails), nail hardeners

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ACRAL SCLEROSIS

ChilblainsBuerger’s disease (thromboangiitis obliterans)Arteriosclerosis obliteransCryoproteinemiasRaynaud’s diseaseRaynaud’s phenomenon (due to collagen vascular disease)Sclerodactyly (secondary to scleroderma, mixed connective tissue

disease, CREST, etc.)Emboli (septic, atherosclerotic)BitesHerpetic whitlowErgot/methysergide toxicity

ANAL AND PERIANAL LESIONS

Sexual abuseCandidiasisSyphilis (primary chancre, secondary)GonorrheaLichen sclerosus et atrophicusLichen planusPsoriasisDermatophyte infectionIntertrigoVitiligoCondylomaHerpes simplexExtramammary Paget’s diseaseBacterial infection (commonly strep)MelanomaMolluscum contagiosumSquamous cell carcinomaVerrucous carcinomaExternal hemorrhoidsCrohn’s diseaseContact dermatitis

GENITAL ULCERS

Behçet’s diseaseMajor apthaeLuetic chancreChancroidFactitialTraumatic

44

Fixed drugLymphogranuloma venereumGranuloma inguinaleHerpes simplexErythema mulitiforme bullosaZoon’s plasma cell balanitis/vulvitisSquamous cell carcinomaScabetic ulcersPyoderma gangrenosumLichen sclerosus et atrophicus/balanitis xerotica

obliterans/kraurosis vulvaeVaricella zoster virus

PENILE LESIONS

Reiter’s syndromeBehçet’s syndromeApthaeErythema multiformeErythroplasia of Queyrat (Bowen’s disease)Contact dermatitis (latex, spermatocides, lubricants, etc.)Lichen planusLichen nitidusPsoriasisScabiesHerpes simplexFixed drug eruptionCandidal balanitisBenign mucous membrane pemphigoidPearly penile papulesSeborrheic keratosesPyodermasSyphilis—chancre, condyloma latumChancroidSquamous cell carcinomaTrauma (bites, factitial, abuse, etc.)Condyloma acuminatumLichen sclerosus et atrophicus (balanitis xerotica obliterans)Giant condyloma of Buschke-Lowenstein (verrucous carcinoma)Granuloma inguinaleLymphogranuloma venereumAngiokeratomaZoon’s balanitisMolluscum contagiosumExtramammary Paget’s disease

45

Bowenoid papulosisNeviFordyce spotsMilial, epidermoid, pilar cystsHemangiomasSclerosing lymphangitis

VULVAR LESIONS

Epidermoid, pilar, milial, Bartholin’s cystsSyphilis—chancre, condyloma latumChancroidCicatrical pemphigoidVitiligoBehçet’s syndromeAngiokeratomaContact dermatitisHemangiomaStreptococcal vaginitisCondyloma accuminataBenign papilloma/soft fibroma/acrochordonBowenoid papulosis/vulvar intraepithelial neoplasm/Bowen’s diseaseFolliculitisLichen sclerosus et atrophicus/kraurosis vulvaeExtramammary Paget’s diseaseCandidal vaginitisSquamous cell/verrucous carcinomaMelanomaFox-Fordyce diseaseFuruncleHidradenitis suppurativaGranuloma inguinaleLymphogranuloma venereumHerpes simplex/zosterErythema multiforme major/Stevens-Johnson syndromeIntertrigoLeukoplakiaLichen planusLichen simplex chronicusMolluscum contagiosumNeviPsoriasisAdnexal carcinomasHidradenoma papilliferumKaposi’s sarcoma

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Seborrheic keratosisNeuroma/neurofibroma

PAINFUL LEG NODULES

Erythema nodosum/induratumGardner-Diamond syndromeCutaneous polyarteritis nodosaAngiolipomaLeiomyomaLupus profundusSubacute nodular migratory panniculitisSuperficial thrombophlebitis/thrombosed varicosityWeber-Christian panniculitisEccrine poromaKaposi’s sarcomaPancreatic panniculitisCutaneous myiasisFuruncleNeuroma/neurofibroma/neurilemmomaInfected epidermoid cyst

LEG ULCERS

Vascular

Arteriosclerosis/thromboangiitis obliteransAtrophie blancheLivedo vasculopathyHypertensive ulcerStasis ulcerLeukocytoclastic vasculitis (see differential of “Vasculitis”)Necrotizing angiitisSeptic emboliPernio

Infectious

Deep fungus (cocci, histo, blasto, crypto, sporo, etc.)Meleney’s ulcerEcthymaAnthraxTularemiaAtypical mycobacteriaTropical ulcerTreponemal disease (syphilis, yaws, pinta, etc.)Madura footLeishmaniasis

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Hematological

Sickle cell ulcerThalassemiasCryopathies

Metabolic

Diabetic dermopathy

Neurologic

Mal perforans ulcerTabes dorsalis

Drug-induced

ErgotHalogenodermasBarbiturate intoxication

Neoplasia

Squamous cell carcinomaMelanomaBasal cell carcinomaMycosis fungoidesKaposi’s sarcomaAngiosarcomaMetastatic carcinoma

Miscellaneous

Traumatic ulcersChemical ulcersFactitialBites (arthropod, snake, etc.)Pyoderma gangrenosumNecrobiosis lipoidica diabeticorumErythema induratumAcrodermatitis chronica atrophicans

COMMON FOOT LESIONS

Piezogenic papules (fat herniation)Surfer’s nodulesMal perforans ulcerMyxoid cystsReiter’s syndromePitted keratolysisPustulosis plantarisDyshidrotic eczema (pompholyx)

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SyphilidPlantar verrucaeClavusInfantile digital fibromaEccrine poromaMelanomaSquamous cell carcinomaSymmetrical lividityHyperkeratosis plantaris/keratoderma/fissured heelDigital fibromatosisKaposi’s sarcomaTinea pedisContact dermatitis“Black heel”CallosityPyodermaCutaneous larva migransEpidermolysis bullosa acquisitaImmersion footErythema multiformeHand, foot, and mouth diseaseLichen planusNeviPityriasis rubra pilarisScabies (especially neonates)Clear cell acanthomaAcute paronychiaOnychodystrophy

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50

V. SPECIAL CLINICAL GROUPS

THE CHILDGENERALIZED VESICULO-PUSTULES INTHE NEONATE

Erythema toxicum neonatorumTransient neonatal pustular melanosisCongenital herpes simplexScabies (especially feet)Staphylococcal impetigo (staph pustulosis)Staph scalded skin syndromeMiliaria rubraMiliaria crystallinaCongenital cutaneous candidiasisIncontinentia pigmenti—first stageCongenital syphilisAcropustulosis of infancyNeonatal lupus

FEBRILE CHILD WITH RASH

Juvenile rheumatoid arthritis/Still’s diseaseAcute systemic lupus erythematosusAcute dermatomyositisViral exanthem (roseola, measles, enterovirus, Fifth disease, etc.)Allergic vasculitis (infection, drug, collagen vascular disease)Serum sicknessRocky mountain spotted feverTyphoid feverSmallpox (variola)Acute hepatitisAcute mononucleosisGonococcemia, meningococcemia, and other bacteremiasRheumatic fever (erythema marginatum)Subacute bacterial endocarditisLyme diseaseScarlet feverKawasaki’s disease (mucocutaneous lymph node syndrome)ErysipelasHenoch-Schönlein purpuraDengue (Texas, Florida)Staphylococcal scalded skin syndromeLeptospirosisHand, foot, and mouth disease (Coxsackie A16 virus)Staph/strep toxic shock syndrome

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Drug hypersensitity syndromeCutaneous polyarteritis nodosa (purpuric papules wrists and ankles, arthralgias, non-specific rash)

ECZEMATOUS ERUPTIONS IN CHILDREN

Atopic dermatitisSeborrheic dermatitisPsoriasisLeiner’s syndromeNetherton’s syndromeContact dermatitisScabiesDiaper dermatitisMolluscum contagiosum (background disease is eczematous)Ritter’s diseaseLangerhan’s cell histiocytosis (Letterer-Siwe disease,

Hand-Schuller-Christian disease)Wiskott-Aldrich syndromeCongenital agammaglobulinemiaAtaxia telangiectasiaPhenylketonuriaAcrodermatitis enteropathicaHurler’s syndromeHartnup’s syndromeAhistidinemiaGluten sensitive enteropathyHyper/hypovitaminosisAsteatosis/xerosisArginine/biotin deficiencyAcute hemorrhagic edema of infancyTinea corporis

BULLAE IN THE NEONATE

Acrodermatitis enteropathicaEpidermolytic hyperkeratosis (bullous congenital ichthyosiform

erythroderma)Incontinentia pigmentiEpidermolysis bullosa (scarring and non-scarring varieties)Juvenile bullous pemphigoidMastocytosis (urticaria pigmentosa)Bullous impetigoBurns (thermal, ultraviolet, etc.)Child abuseStaphylococcal scalded skin syndrome

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OTHER SPECIAL GROUPSCUTANEOUS MANIFESTATIONS OF HIV

Exanthem of acute HIV (acute morbilliform rash)Periodontal diseaseAphthaeFolliculitis (bacterial, candidal, fungal)Eosinophilic folliculitisScabiesSeborrheic dermatitisKaposi’s sarcomaHerpes simplex/zosterMolluscum contagiosumVerruca/condylomaOral hairy leukoplakiaCutaneous candidiasisTinea versicolorTinea corporisDeep fungal nodules (crypto, histo, etc.)Generalized pruritusLipoatrophy (especially malar areas)Melanonychia (longitudinal, from zidovudine)

DERMATOSES OF PREGNANCY

Pruritic

Pemphigoid gestationis—bullous pemphigoid-like; pruriticplaques, vesicles, bullae; positive IgG at BM; second trimester;may persist postpartum; increased incidence of prematurity;periumbilical area involved; treatment: oral prednisone.

Polymorphic eruption of pregnancy (pruritic urticarial papulesand plaques of pregnancy [PUPPP])—third trimester;abdomen and thighs; remits postpartum; common (1 in 225pregnancies); very pruritic; treatment: topical or oral steroids.

Pruritus gravidarum (intrahepatic cholestasis of pregnancy)—severe pruritus; no primary lesions except excoriations;jaundice; decreased vitamin K; third trimester; nausea andvomiting; elevated liver enzymes; increased fetal distress;remits postpartum; treatment: powerful antipruritics.

Prurigo gestationis of Besnier—grouped excoriated paples andprurigo nodules usually on extensor surfaces of extremities;last trimester; atopic diathesis; resolves post partum; nomaternal/fetal complications; treatment: topical steroids.(Likely the same disorder as papular dermatitis of pregnancydescribed by Spangler.)

53

Impetigo herpetiformis—may be form of pustular psoriasis; flexural; third trimester; may be complicated by hypoparathyroidsim and hypocalcemia and its assoc. problems; spares face, hands, and feet; remits post partum; increased maternal and fetal mortality; treatment: prednisone, calcium.

Non-pruritic

Striae distensaeLinea nigraChange in size, shape, and elevation of benign neviMelasma

SKIN LESIONS ASSOCIATED WITHACUTE ARTHRITIS

Gonococcal arthritisAcute rheumatic feverSerum sicknessStill’s diseaseReiter’s syndromeSubacute bacterial endocarditisAcute rheumatic arthritisViral syndromes (hepatitis, mononucleosis, etc.)Systemic lupus erythematosusAcute dermatomyositisPsoriatic arthritisHenoch-Schönlein purpuraKawasaki’s diseaseGoutDengueMeningococcemiaCutaneous polyarteritis nodosaAcute graft vs. host reactionDrug hypersensitivity reaction

PRURITUS (GENERALIZED)(No primary lesions)

Stress, psychogenicLiver disease (biliary cirrhosis, etc.)Uremia of renal failureHyperthyroidism/Hashimoto’s thyroiditisDiabetesLymphoma, leukemiaHodgkin’s diseaseAbdominal malignancies

54

Drug reactionPhotosensitivity/phototoxic reactionHookwormOnchocerciasisBody liceXerosisPregnancy (see differential of “Dermatoses of Pregnancy—Pruritic”)Polycythemia rubra vera (especially after hot bath)Caffeine ingestionAcquired anhidrosis (due to metal poisoning, CNS disease, or endocrine disease)DermatographismAcute hepatitisHIVNotalgia paresthetica (usually localized to subscapular area)MastocytosisDemyelinating diseasesDelusions of parasitosisFilariasisSchistosomiasisScabies

55

56

VI. APPENDIX

CUTANEOUS CLUES TO SYSTEMIC DISEASE

Skin color

Orange—carotenemiaWhite—albinism, generalized vitiligoYellow—Liver disease (jaundice)Gray—hemochromatosis, argyriaBrown—Addison’s disease, pituitary tumors, chronic minocycline ingestion, chronic UVA/UVB abuseBlue—cyanosis, pulmonary disease, methemoglobinemia,

alkaptonuria (ears)Black—melanoma

Hypertrichosis—porphyria cutanea tarda, polycystic ovarian disease, excess androgen syndromes, hypertrichosis lanuginosa due to internal malignancies-especially lung

Angioedema—dermal urticaria, hereditary angioneurotic edema (usually face and ears + glossitis—assoc. with systemic malignancies especially lung)

Lentigines—LEOPARD syndrome, Peutz-Jeghers syndromeAcanthosis nigricans—internal malignancy, especially endocrineCafé-au-lait spots—von Recklinghausen’s disease,

Albright’s syndromeEruptive keratoacanthomas—internal malignancy, immunosuppression (especially organ transplant patients)Pruritus—many etiologies: biliary, uremic, thyroid, hepatitis, HIVEruptive seborrheic keratoses—internal malignancyDermatitis herpetiformis—gluten enteropathyPyoderma gangrenosum—inflammatory bowel disease, rheumatoid arthritis, internal malignancy (especially colon)Nevus flammeus—Sturge-Weber syndromeExfoliative erythroderma—drug reactions, underlying eczematous diseases, Sézary’s syndrome, internal malignancies (especially

lymphomas)Urticaria—drugs, foods, infection, stress, internal disease, hepatitisErythema multiforme—infection (eespecially herpes simplex), drug, occult diseaseTelangiectasia—liver disease, Osler-Weber-Rendu syndrome,

radiation, collagen vascular disease, congenital syndromesEczema in children—histiocytosis, immunodeficiency disease, atopy

57

Eruptive xanthomas—lipid disordersAcquired ichthyosis—drug reactions, Hodgkin’s disease, leukemias,

sarcoidosisSebaceous adenomas/sebaceous carcinomas—Muir-Torre

syndrome (colon, breast, GU malignancies)Necrolytic migratory erythema—glucagonoma syndromePorphyria cutanea tarda—hepatitis C and/or HIV, chemical expo-

sure, liver/iron disorders, NSAID use (pseudoporphyria)Extensive seborrheic dermatitis—HIVLichen planus—hepatitis CFacial and oral papillomas—Cowden’s diseaseAngiofibromas—tuberous sclerosisAngiokeratomas—Fabry’s disease and related storage diseasesLivedo—vasculitis, collagen vascular disease,

antiphospholipid syndromeNecrobiosis lipoidica—diabetesExtramammary Paget’s—underlying adenocarcinomaAcrosclerosis—scleroderma, angiitis, chilblains, cryopathiesErythema gyratum repens—breast or colon cancerKnuckle papules (Gottron’s nodes)—dermatomyositisMultiple acrochordons—malignant colon polypsMultiple epidermoid cysts—Gardner’s syndrome

DERMATOLOGIC EMERGENCIES(Yes, there are a few!)

Necrotizing fasciitisCellulitis—especially hand, feet, and central facialErysipelasPurpura fulminansNeonatal herpes simplexGenital herpes in antepartum femaleDisseminated herpes zosterAngioedema with tracheal obstructionHereditary angioneurotic edema—acute attackExfoliative erythrodermaGonococcemia, meningococcemiaToxic epidermal necrolysisStevens-Johnson syndromeStaphylococcal scalded skin syndromeStaph/strep toxic shock syndromeDrug hypersensitivity syndromeKaposi’s varicelliform eruption/eczema vaccinatumRocky mountain spotted feverCavernous hemangioma with airway obstruction

58

PlagueAnthraxSmallpoxKawasaki DiseaeAcute DermatomyositisPemphigus vulgarisNodular or ulcerating melanomaPrimary luetic chancreBrown recluse spider or black widow bite in infant

59

60

Acneiform lesions . . . . . . . .30Acral sclerosis . . . . . . . . . . .44Acute dermatomyositis . . . . .51Acute generalized

red papules . . . . . . . . . . . .7AIDS/HIV . . .10, 29, 31, 37, 40,

41, 53, 55, 57, 58Alopecia

non-scarring . . . . . . . .31-32scarring . . . . . . . . . . . . . .32

Anal and perianal lesions . . .44Annular papules . . . . . . . . . . .5Annular plaques . . . . . . . . .7-8Anthrax . .11, 12, 15, 22, 23, 47Appendageal tumors . . . . .9, 14Arthritis with skin lesions . . .54Atrophic patches . . . . . . . . . . .4Axilla, pigmented

lesions . . . . . . . . . . . .41-42

Black,nails . . . . . . . . . . . . . . . . .43skin . . . . . . . . . . . . . . . . .57

Blue,nails . . . . . . . . . . . . . . . . .43papules . . . . . . . . . . . .36-37skin . . . . . . . . . . . . . . . . .57

Brown,macules . . . . . . . . . . . . .3-4nails . . . . . . . . . . . . . . . . .43papules . . . . . . . . . . . .37-38recluse spider . . .22, 23, 32skin . . . . . . . . . . . . . . . . .57

Bullae . . . . . . . . . . . . . . .16-18Bullae in the neonate . . . . . .52

Chancre . . . . . . .41, 44, 45, 46Child,

arthritis with rash . . . .51, 54bullae . . . . . . . . . . . . . . . .52erythroderma . . . . . . . . . .29eczematous eruptions . .25, 52febrile child with rash . .51-52vesiculo-pustules . . . . . . .51

Cords, subcutaneous . . . . . . .14Cysts . . . . . . . . . . . . . . . . . .9, 14

Definitions . . . . . . . . . . . . . . . .1Dermal tumors and

nodules . . . . . . . . . . . . . .8-10Dermatitis . . . . . . . . . . . . . . .25Dermatitis,

in child . . . . . . . . . . . . . . .52exfoliative . . . . . . . . . .28-29

Desquamation . . . . . . . . .28-29Draining lesions . . . . . . . . . .34Dystrophies, nail . . . . . . . . . .43

Ecchymoses . . . . . . . . . . . . .21Eczema . . . . . . . . . . . . . . . . .25Eczema,

in children . . . . . . . . . . . .52Emergencies . . . . . . . . . . . . .58Erythema . . . . . . . . . . . . .19-20Erythroderma . . . . . . . . . . . .29Exfoliation . . . . . . . . . . . .28-29

Face,destructive midlinelesions . . . . . . . . . . . . .38-39lupoid lesions . . . . . . . . . .38papules . . . . . . . . . . . .36-38vesicles . . . . . . . . . . . . . . .16

Febrile child with rash . . .51-52Feet,

common lesions . . . . .48-49vesicles and bullae . . .17-18

Fever and rash in child . .51-52

Genital,penis lesions . . . . . . . .45-46ulcers . . . . . . . . . . . . .44-45vulvar lesions . . . . . . .46-47

Granulomatous lesions . . .9, 34Gray,

nails . . . . . . . . . . . . . . . . .43skin . . . . . . . . . . . . . . . . .57

INDEX

61

Hair loss . . . . . . . . . . . . .31-32Hands,

bullae . . . . . . . . . . . . .17-18hyperkeratosis . . . . . . . . .27inflammatory nodules . . . .11purpura . . . . . . . . . . . . . .42pustules . . . . . . . . . . . . . .42vesicles . . . . . . . . . . . .17-18

Hemorrhagic vesicles . . . . . .18HIV/AIDS . . . . . . .See AIDS/HIVHyperkeratosis,

generalized . . . . . . . . .26-27palms and soles . . . . . . . .27

Hyperkeratoticpapules . . . . . . . . . . . . . .5-6plaques . . . . . . . . . . . . . .28

Hyperpigmentation, axilla . .41-42Hyperpigmented macules . .3-4Hypomelanosis . . . . . . . . . . . .3Hypopigmentation . . . . . . . . . .3

Ichthyosis . . . . . .6, 25, 26, 27,28, 30, 58

Infarctions . . . . . . . . . . . . . .23Infectious ascending

nodules . . . . . . . . . . . . . . .13Infectious nodules . . . . . . . .12Inflammatory nodules . . .10-11

Kawasaki’s disease . . . . .28, 31,51, 54

Koebnerizing lesions . . . .33-34

Legs,inflammatory nodules . .10-11painful nodules . . . . . . . .47ulcers . . . . . . . . . . . . .47-48

Lichenoid papules . . . . . . . . . .6Linear papules . . . . . . . . . . . .6Lip lesions . . . . . . . . . . . . . .39Lupus-like lesions of the

face . . . . . . . . . . . . . . . . . . .38Lymphadenitis,

ulcers with . . . . . . . . . .22-23

Macules,brown . . . . . . . . . . . . . . .3-4white . . . . . . . . . . . . . . . . .3

Melanoma . . . . . . .3, 8, 10, 13,22, 35, 37, 38, 39, 41,43, 44, 46, 48, 49, 57

Midline face lesions . . . . .38-39Morbilliform eruptions . . . . .31Mouth,

lesions . . . . . . . . . . . .39-41papules and plaques . .40-41ulcers . . . . . . . . . . . . . . . .40white lesions . . . . . . . . . .40

Mucosal lesions . . . . . . . .39-41

Nails . . . . . . . . . . . . . . . . . .43Necrotic lesions . . . . . . . . . .23Neonate,

with bullae . . . . . . . . . . . .52with vesiculo-pustules . . . . .51

Nodular or ulceratingmelanoma . . . . . . . . .10, 22

Nodules,infectious ascending . . . . .13inflammatory . . . . . . . .10-11painful leg . . . . . . . . . . . .47red . . . . . . . . . . . . . . .11-13subcutaneous . . . . . . .13-14

Non-palpable purpura . . . . .21

Onycholysis . . . . . . . . . . . . .43Oral mucosa lesions . . . .39-41Orange,

nails . . . . . . . . . . . . . . . . .43skin . . . . . . . . . . . . . . . . .57

Painful leg nodules . . . . . . . .47Painful tumors . . . . . . . . . . .15Palms,

hyperkeratotic . . . . . . . . .27purpura . . . . . . . . . . . . . .42pustules . . . . . . . . . . . . . .42

Palpable purpura . . . . . . . . .20

62

Papules,acneiform . . . . . . . . . . . . .30acute generalized red . . . . .7annular groupings . . . . . . .5blue . . . . . . . . . . . . . .36-37brown . . . . . . . . . . . . .37-38face . . . . . . . . . . . . . . .36-38flesh colored . . . . . . . . . .37hyperkeratotic . . . . . . . . .5-6intraoral . . . . . . . . . . .40-41lichenoid . . . . . . . . . . . . . .6linear . . . . . . . . . . . . . . . . .6lupoid . . . . . . . . . . . . . . .38pregnancy-related . . . .53-54red . . . . . . . . . . . . . . . . . . .7yellow . . . . . . . . . . . . . . . .36

Papulosquamous diseases . . .25Patches, atrophic . . . . . . . . . .4Pemphigoid, bullous . .16, 18, 39

52, 53Pemphigus vulgaris . . . . .16, 39Perianal and anal lesions . . .44Penile lesions . . . . . . . . .45-46Pigmentation,

axillary . . . . . . . . . . . .41-42hyper– . . . . . . . . . . . . . .3-4hypo– . . . . . . . . . . . . . . . . .3

Petechiae . . . . . . . . . . . . . . .21Plague . . . . . . . . . . . . . . . . . .22Plaques,

annular . . . . . . . . . . . . . .7-8hyperkeratotic . . . . . . . . .28mouth . . . . . . . . . . . . .40-41red . . . . . . . . . . . . . . . . . . .8

Pregnancy,dermatoses of . . . . . . .53-54pruritis in . . . . . . . . . .53-54

Primary lesions . . . . . . . . . . . .1Primary luetic chancre . .(See also

“Syphilis”) . . . .41, 44, 45, 46Pruritus,

generalized . . . . . . . . .54-55pregnancy . . . . . . . . . .53-54

Purpura,non-palpable . . . . . . . . . .21palms and soles . . . . . . . .42palpable . . . . . . . . . . . . . .20

Pustular eruptions . .15-16, 42, 51Pustules,

neonate . . . . . . . . . . . . . .51palms and soles . . . . . . . .42

Red,generalized papules . . . . . .7nodules . . . . . . . . . . . .11-13papules . . . . . . . . . . . . . .36plaques . . . . . . . . . . . . . . .8skin . . . . . . . . . . . .19-20, 29

Scalp lesions . . . . . . . . . . . .35Scarring alopecia . . . . . . . . .32Scarring lesions . . . . . . . .32-33Scars, lesions in . . . . . . . .33-34Sclerosis, acral . . . . . . . . . . .44Sclerotic lesions . . . . . . . . . .33Serpiginous lesions . . . . .30-31Smallpox . .16, 17, 18, 23, 42, 51Soles, . . . . . . . . . . . . . . . . . . . .

hyperkeratotic . . . . . . . . .27purpura . . . . . . . . . . . . . .42pustules . . . . . . . . . . . . . .42

Sporotrichoid lesions . . . . . .13Subcutaneous cords . . . . . . .14Subcutaneous nodules . . .13-14Syphilis . . . . . .3, 20, 22, 23, 25,

30, 31, 32, 36, 38, 40, 41,42, 44, 45, 46, 47, 51

Systemic disease (clues) . .57-58

Telangiectasia . . . . . . . . .18-19Tongue lesions . . . . . . . . . . .41Trunk, vesicles and

bullae . . . . . . . . . . . . .16-17Tumors . . . . . . . . . . . .8-10, 15Tumors, painful . . . . . . . . . .15

63

Ulceroglandular diseases . .22-23Ulcers,

face (see destructive midlinelesions) . . . . . . . . . .38-39

genital . . . . . . . . . . . . .44-45leg . . . . . . . . . . . . . . . .47-48oral . . . . . . . . . . . . . . . . .40

Vascular nodules . . . . . .11-12Vasculitis . . . . . . . . . . . . .20, 21Verrucous lesions . . . . . . . . .26Vesicles . . . . . . . .16-18, 39-40Vesicles,

hemorrhagic . . . . . . . . . .18neonatal . . . . . . . . . . . . . .51oral . . . . . . . . . . . . . . .39-40

Vesiculo-pustules, neonate . .51Vulvar lesions . . . . . . . . .46-47

Wheal . . . . . . . . . . . . . . . . . .1White,

lesions in the mouth . . . . .40macules . . . . . . . . . . . . . . .3nails . . . . . . . . . . . . . . . . .43papules . . . . . . . . . . . . . .36skin . . . . . . . . . . . . . . . . .57

Yellow,nails . . . . . . . . . . . . . . . . .43papules . . . . . . . . . . . . . .36skin . . . . . . . . . . . . . . . . .57

64

NOTES

65

NOTES

66

NOTES

67

NOTES

68