Dermatologija Atlas u Boji

May 8, 2018 | Author: Armen Meskic | Category: Dermatitis, Cutaneous Conditions, Herpes Simplex, Infection, Public Health
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Dermatologija...

Description

alphabetical

page: 1

Chapter 1:

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basic lesion

cause

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Histological reminder of the structure of human skin

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page: 2

alphabetical

Histological reminder of the structure of human skin

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cause basic lesion

The three constituents are, from top to bottom, the epidermis (coloured in red), the dermis (coloured in blue) and the hypodermis (or subcutaneous adipocytic tissue) packed with sudoriparous glands which are either small (eccrine glands) or large (apocrine glands). Hairs and small sebaceous glands are identifiable in the dermis (coloration : Masson blue trichromatic; enlargement : x 25).

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Skin from the axillary region

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alphabetical

Histological reminder of the structure of human skin

The three constituents are clearly recognisable from top to bottom : the epidermis (thin red border), the dermis (coloured in orange) and the subcutaneous adipocytic tissue. The fine hairs and the sebaceous glands are very numerous in the dermis, but one finds only a small number of sudoriparous glands (coloration : haemalun-eosinesafran; enlargement : x 25).

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basic lesion

It nicely illustrates the regional varieties of the integument, compared to the axillary skin.

cause

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Skin from the forehead region

All the signs of physiological lightageing are present : disorganised epidermis, elastic transformation of the collagen fibres of the dermis. Under a thin strip of normal subepidermal collagen tissue (coloured in yellow) there appear large degenerated elastic collagen fibres (coloured in red), (coloration : haemalun-eosine-safran; enlargement : x 100).

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Skin from the face of an elderly subject

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alphabetical

page: 4

basic lesion

Histological reminder of the structure of human skin

page: 5

alphabetical

Histological reminder of the structure of human skin

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cause basic lesion

Close-up of the epidermis. This includes three cell types : the keratinocytes, the melanocytes and the cells of Langerhans. Two are recognisable on this photo : the keratinocytes very coherent among one another, and in the basal stratum several melanocytes surrounded by a light halo (coloration : haemalun-eosinesafran; enlargement : x 250).

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Structure of the epidermis

page: 6

alphabetical

Histological reminder of the structure of human skin

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Close-up of the epidermis. Melanin coloured by the Fontana method. The melanocytes appear like crazed, dendritic cells in the basal stratum of the epidermis. They transfer the melanin to the keratinocytes, which are diffusely tattooed with it (enlargement: x 250).

basic lesion

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Structure of the epidermis

page: 7

alphabetical

Histological reminder of the structure of human skin

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cause

Close-up of the epidermis. Highlighting of the cells of Langerhans, which appear like dendritic cells covering all of the living epidermis. These cells belong to the line of histiocytic cells and play the immunological role of antigen-presenting cells (immunomarking OKT6 in peroxidase; enlargement : x 250).

basic lesion

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Structure of the epidermis

alphabetical

page: 8

Chapter 2:

basic lesion

cause

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Basic lesions

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Macules

2.1

page: 9

alphabetical

Basic lesions

Macules

basic lesion

The skin coloration varies from pale pink to dark red and disappears on vitropression. It is the result of more or less intense vasodilation (e.g. blushing from modesty).

cause

A macule is a non-infiltrated mark which differs in colour from adjacent skin.

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Erythematous macule

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Macules

page: 10

alphabetical

Basic lesions

cause basic lesion

These permanent marks, which disappear partially or completely on vitropression, result from the presence of an abundant network of dilated vessels in the superficial dermis (e.g. telangiectasia).

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Vascular macule

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Macules

page: 11

alphabetical

Basic lesions

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Purpuric macule

basic lesion

cause

The red macules do not disappear on vitropression. They are the result of extravasation of blood into the dermis (e.g. Bateman's purpura). Their colour changes in time from red to ochre.

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Macules

page: 12

alphabetical

Basic lesions

basic lesion

varying in size, their colour ranging from ochre to dark brown, corresponding to melanin hyperpigmentation in the epidermis (e.g. freckles).

cause

Pigmented macules

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Pigmentary macules

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Pigmentary macules

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page: 13

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Blueish-grey macules

basic lesion

are the result of melanin deposits extending more or less deeply into the dermis. (e.g. paresthetic notalgia)

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Macules

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Basic lesions

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Pigmentary macules

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page: 14

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Achromic macules

basic lesion

are white marks, varying in shape and size, which result from a decrease in the melanin content of the epidermis (e.g. vitiligo).

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Macules

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Basic lesions

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Papules

2.2

page: 15

alphabetical

Basic lesions

Papules

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Papules are more or less well demarcated elevations of varying size. There are 3 papule types.

Epidermal papules

basic lesion

cause

These correspond to global thickening of the epidermis (e.g. plane warts).

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Papules

page: 16

alphabetical

Basic lesions

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Dermal papules

basic lesion

cause

These correspond to oedematous, inflammatory, or proliferative thickening of the dermis (e.g. the weal of urticaria).

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Papules

page: 17

alphabetical

Basic lesions

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Dermo-epidermal papules

basic lesion

cause

These correspond to a mixed thickening of the epidermis and dermis. (e.g. lichen planus)

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2.3

page: 18

alphabetical

Nodules

Nodules

basic lesion

cause

Nodules are hemispherical elevations caused by inflammatory and oedematous infiltrations of the deep dermis and subcutis (e.g. rheumatoid nodule).

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Basic lesions

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2.4

page: 19

alphabetical

Tubercles

Tubercles

basic lesion

cause

Tubercles are solid, prominent, circumscribed formations, superficially encased in the dermis. They sometimes ulcerate in the course of their development (e.g. lupus vulgaris [tuberculosis]).

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Basic lesions

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2.5

page: 20

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Vegetations

Vegetations

basic lesion

cause

Vegetations are filiform or lobulate excrescences, generally of soft consistency (e.g. condylomata acuminata).

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Basic lesions

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2.6

page: 21

alphabetical

Warts

Warts

basic lesion

cause

Warts are vegetations covered with a more or less thick horny layer (e.g. common wart).

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Basic lesions

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2.7

page: 22

alphabetical

Keratoses

Keratoses

basic lesion

cause

Keratoses consist of epidermal lesions characterized by a localized accumulation of keratin (e.g. cutaneous horn).

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Basic lesions

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2.8

page: 23

alphabetical

Vesicles

Vesicles

basic lesion

cause

Vesicles are small cutaneous protuberances with a central cavity containing clear liquid. They are often hemispherical and their centre can be depressed (e.g. varicella).

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Basic lesions

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Bullae

2.9

page: 24

alphabetical

Basic lesions

Bullae

basic lesion

cause

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Bullae are more voluminous elevations with a central cavity containing a clear, cloudy, or haemorrhagic liquid. They vary in dimensions and in tension: flaccid of firm bullae (e.g. bulla of a thermal burn).

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2.10

page: 25

alphabetical

Pustules

Pustules

basic lesion

cause

Pustules are protuberances which vary in size and have a central cavity containing a purulent liquid. They occur as primary lesions or develop from vesicles or bullae (e.g. palmoplantar pustulosis).

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Basic lesions

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2.11

page: 26

alphabetical

Scales

Scales

basic lesion

cause

Scales are aggregates of more or less dry horny cells formed by the superficial layers of the epidermis. They detach in fragments of varying size (e.g. ichthyosis).

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Basic lesions

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2.12

page: 27

alphabetical

Crusts

Crusts

basic lesion

cause

Crusts are concretions of fairly hard consistency which result when exudative, haemorrhagic, or purulent lesions dry out (e.g. impetigo).

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Basic lesions

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Excoriations (or ulcerations)

2.13

page: 28

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Basic lesions

Excoriations (or ulcerations)

basic lesion

cause

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Excoriations are very superficial wounds. The dermis is exposed (e.g. excoriations caused by scratching).

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2.14

page: 29

alphabetical

Fissures

Fissures

basic lesion

cause

Fissures are linear ulcers, with or without marginal hyperkeratosis, which break through the superficial dermis (e.g. athlete's foot).

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Basic lesions

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Ulcers

2.15

page: 30

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Basic lesions

Ulcers

basic lesion

cause

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Ulcers are more serious losses of substance, which penetrate deep into the dermis (e.g. slough).

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Gangrene

2.16

page: 31

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Basic lesions

Gangrene

basic lesion

cause

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Gangrene is tissue necrosis associated with loss of arterial or arteriolar blood supply (e.g. frostbite).

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Atrophy

2.17

page: 32

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Basic lesions

Atrophy

basic lesion

cause

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Atrophy consists of a reduction in skin thickness with loss of its firmness and elasticity (e.g. senile atrophy).

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2.18

page: 33

alphabetical

Scars

Scars

basic lesion

cause

Scars are due to modifications of the dermis or epidermis and are a sign of a variable degree of fibrosis. They are the evidence of repair of a wound or of a loss of substance (e.g. scar after a burn).

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Basic lesions

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2.19

page: 34

alphabetical

Sclerosis

Sclerosis

basic lesion

cause

Sclerosis means induration of the skin, which loses its normal suppleness. It is associated with coalescence of fibres in the dermis (e.g. morphoea).

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Basic lesions

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alphabetical

page: 35

Chapter 3:

basic lesion

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Eczemas

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Allergic contact dermatitis and irritation dermatitis Acute exudative contact dermatitis Acute exudative allergic contact dermatitis of the flexor surfaces of the forearms and arms after repeated application of an antiseptic lotion. Allergic reaction to hexamidine. Countless small translucent vesicles on a background of congestive erythema, rupturing and exuding a clear serous liquid.

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3.1

page: 36

cause

Allergic contact dermatitis and irritation dermatitis

basic lesion

Eczemas

alphabetical

page: 37

Chronic occupational contact dermatitis

basic lesion

Slightly keratotic, cracked, and infected scaly erythematous lesions of the back of the fingers in a mason. Allergic reactions to chromium salts present in cements.

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Allergic contact dermatitis and irritation dermatitis

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Eczemas

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Allergic contact dermatitis and irritation dermatitis

page: 38

alphabetical

Eczemas

cause basic lesion

Acute erythematous papulovesicular allergic contact dermatitis of the backs of the hands in a physiotherapist. Allergic reaction to the lanolin contained in a massage cream. The right hand is more severely affected than the left.

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Vesicular contact dermatitis

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Allergic contact dermatitis and irritation dermatitis

page: 39

alphabetical

Eczemas

basic lesion

The diffuse erythema, with an unsharp and fragmented margin, is covered with small translucent vesicles.

cause

continued

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Vesicular contact dermatitis

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Allergic contact dermatitis and irritation dermatitis

page: 40

alphabetical

Eczemas

cause basic lesion

Acute allergic contact dermatitis of the dorsal surface of the forefoot and toes. Allergic reaction to chromium salts used to tan shoe leather.

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Bullous contact dermatitis

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Allergic contact dermatitis and irritation dermatitis

page: 41

alphabetical

Eczemas

continued

basic lesion

cause

Bullae are formed on an erythematous vesicular background.

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Bullous contact dermatitis

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Allergic contact dermatitis and irritation dermatitis

page: 42

alphabetical

Eczemas

cause basic lesion

Allergic contact dermatitis to the nickel in a jeans stud. At the point of contact there is a crusty greyish patch, partly eroded by excoriations caused by scratching.

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Crusted eczema

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page: 43

Crusted eczema

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Allergic contact dermatitis and irritation dermatitis

continued

basic lesion

cause

At the edges an erythematous papulovesicular eczema extends to an unclear margin.

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Eczemas

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Allergic contact dermatitis and irritation dermatitis

page: 44

alphabetical

Eczemas

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Scaly dry erythematous contact dermatitis

basic lesion

cause

Allergic contact dermatitis of the eyelids caused by the use of an antiwrinkle cream. Allergic reaction to Kathon CG®, the cream's preservative. Diffused demarcated and itchy erythematous patches of eczema with fine scales.

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Allergic contact dermatitis and irritation dermatitis

page: 45

alphabetical

Eczemas

cause basic lesion

Acute irritant dermatitis of the back of the hand and fingers, caused by contact with detergents. Diffuse itchy erythema. The margins of the erythema are distinct, corresponding to the zone of contact with the irritants.

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Acute irritant dermatitis

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page: 46

Cumulative insult dermatitis or chronic irritant dermatitis

basic lesion

Chronic irritant dermatitis of the back of the hand and fingers caused by contact with detergents. Scaly keratotic and chapped erythema causing pruritus and pain.

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Allergic contact dermatitis and irritation dermatitis

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Eczemas

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page: 47

Chronic palmar irritant dermatitis

basic lesion

Thick greyish or blackish keratotic patches, which are fissured and chapped. The clinical picture results from the combination of physical (friction, microtraumata) and chemical factors.

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Allergic contact dermatitis and irritation dermatitis

cause

Eczemas

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alphabetical

3.2

page: 48

Constitutional eczema or atopic dermatitis Atopic dermatitis of the face in an infant

basic lesion

Bright red oedematous patches of eczema with weeping vesicles. The margins are poorly defined. The lesions predominate on the convex areas of the face: forehead, cheeks, chin.

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Constitutional eczema or atopic dermatitis

cause

Eczemas

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page: 49

Infected retro-auricular dermatitis

basic lesion

Itchy exudative erythematous lesions of the retro-auricular groove, centred on a fissure at the base of the fold. Yellowish crusts are the sign of a microbial infection. These lesions, classical in childhood, can persist into adulthood.

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Constitutional eczema or atopic dermatitis

cause

Eczemas

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Constitutional eczema or atopic dermatitis

page: 50

alphabetical

Eczemas

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Atopic dermatitis of childhood

basic lesion

cause

Very itchy exudative eczematous lesions of the eyelids and atopic angular cheilitis.

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page: 51

Atopic dermatitis of the folds in a child

basic lesion

Lichenified and very itchy patches in the knee flexures, transversed by scratch lines. In the present case similar lesions are present in other folds (e.g. of elbows, behind the ears, under the buttocks). The lesions can persist into adulthood.

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Constitutional eczema or atopic dermatitis

cause

Eczemas

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Excoriations (or Ulcerations)

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Constitutional eczema or atopic dermatitis

page: 52

alphabetical

Eczemas

Eczema of the nipples picture

Sign of atopic dermatitis in adulthood

basic lesion

cause

Acute exudative eczematous lesions of the nipple, the areola, and the periareolar region. The lesion margins are indefinite, the pruritus intense, and the course chronic. This is a classical sign of atopy in adulthood.

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Constitutional eczema or atopic dermatitis

page: 53

alphabetical

Eczemas

cause basic lesion

Atopic cheilitis affects the upper and lower lips and extends over the perioral region. Dry eczematous lesions causing chronic desquamation.

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Atopic cheilitis

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Scales; Fissures

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Atopic dermatitis in the adult: xerosis, lichenification and prurigo Very particular polymorphism of the lesions: skin dry and rough (xerosis), lichenified patches. There are also papules of various sizes, very strongly infiltrated, hard in consistency and often excoriated. These are prurigo papules (which used to be called "Besnier's prurigo").

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alphabetical

page: 54

cause

Constitutional eczema or atopic dermatitis

basic lesion

Eczemas

Constitutional eczema or atopic dermatitis

page: 55

alphabetical

Eczemas

cause basic lesion

Atopic conjunctivitis associated with blepharitis. This inflammation of the conjunctiva is embarrassing, sometimes painful, and often distressingly chronic. It is not unusual in the atopic adult.

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Atopic conjunctivitis

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Atopic dermatitis of the hands in the adult Chronic scaly erythematous eczema of the back of the hands. One quite characteristic feature is the irregular distribution (patchy pattern) of the lesions. Some fingers are affected, whereas others are not. The back of the hands is irregularly affected. This "disordered" topography of the lesions is frequently found in atopic dermatitis.

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alphabetical

page: 56

cause

Constitutional eczema or atopic dermatitis

basic lesion

Eczemas

Constitutional eczema or atopic dermatitis

page: 57

alphabetical

Eczemas

cause basic lesion

Rounded patch of dry scaly erythematous eczema on the cheek of a child. Spontaneous healing with a tendency to transient residual depigmentation, whence the name pityriasis alba. It occurs more frequently in atopic patients.

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Pityriasis alba

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Constitutional eczema or atopic dermatitis

page: 58

alphabetical

Eczemas

cause basic lesion

This condition, the site of which is generally the anterior third of the sole, always bilateral, and often symmetrical, is characterized by the triad of erythema, hyperkeratosis, and fissures.

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Juvenile plantar dermatosis

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Constitutional eczema or atopic dermatitis

page: 59

alphabetical

Eczemas

basic lesion

The skin often has a shiny collodion-like appearance. It often becomes worse in winter and is perhaps more common in atopic patients ("atopic winter feet").

cause

continued

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Juvenile plantar dermatosis

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Nummular dermatitis (discoid eczema)

3.3

page: 60

alphabetical

Eczemas

Nummular dermatitis (discoid eczema)

basic lesion

cause

Round erythematous plaque (nummulus = coin) covered with numerous weeping vesicles which develop into small crusts.

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Exudative variety

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Nummular dermatitis (discoid eczema)

alphabetical

page: 61

continued

Dry variety of nummular dermatitis

basic lesion

Several round or oval erythematous plaques, well demarcated and isolated from each other. Their diameter varies from one to several centimetres and they are covered in fine dry scales.

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Nummular dermatitis (discoid eczema)

cause

Eczemas

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Gravitational eczema

3.4

page: 62

alphabetical

Eczemas

Gravitational eczema

basic lesion

cause

picture

Patches of itchy erythematous dry eczema, often accompanied by scratches. The lesions are sometimes situated along the course of varicose vessels.

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Seborrhoeic dermatitis

3.5

page: 63

alphabetical

Eczemas

Seborrhoeic dermatitis

picture

Seborrhoeic dermatitis of the trunk

basic lesion

cause

Red circinate plaques in the presternal and/or interscapular region, covered in slightly itchy greasy scales. Very slight depigmentation occurs in the centre of the lesion.

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Seborrhoeic dermatitis of the hairline On the scalp it is characterized by diffuse itchy erythema covered in greasy scales. The lesions sometimes spread to the forehead, as in the present case, where they form what is commonly known as the corona seborrhoeica: erythematous patches dotted with steatoid scales, which, following the hairline, show scalloped and arched margins.

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alphabetical

page: 64

cause

Seborrhoeic dermatitis

basic lesion

Eczemas

alphabetical

page: 65

Seborrhoeic dermatitis of the face

basic lesion

The scaly erythematous lesions are well demarcated and have characteristic sites: hairline, nasolabial folds, vertical mediofrontal fold, and the free edges of the lower eyelids.

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Seborrhoeic dermatitis

cause

Eczemas

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Pompholyx

3.6

page: 66

alphabetical

Eczemas

Pompholyx

cause basic lesion

The vesicles of pompholyx are arranged in groups on the lateral sides of the fingers. They are hard to the touch, encased in the epidermis, translucent, and classically compared to grains of sago or to cooked tapioca. They are accompanied by intense itching.

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Pompholyx of the fingers

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page: 67

Bullous pompholyx of the palms (cheiro-pompholyx)

basic lesion

The vesicles encased in the palmar epidermis coalesce to form true bullae, which are sometimes haemorrhagic.

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Pompholyx

cause

Eczemas

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page: 68

Eczematous pompholyx of the palms

basic lesion

Eczematous pompholyx represents an association of pompholyx vesicles with scaly erythematous patches with diffuse margins. The itching is fierce and the course is characterized by successive, even subintrant episodes.

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Pompholyx

cause

Eczemas

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3.7

page: 69

Asteatotic eczema (or winter eczema, eczéma craquelé, or erythema craquelé)

basic lesion

Dry eczema with imprecise margins reminiscent of crazy paving. The cracks in the "paving" correspond to fissures of variable depth, with pinpoint bleeding. The name "erythema craquelé" is nowadays preferred to "eczéma craquelé".

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Asteatotic eczema

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Eczemas

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page: 70

Chapter 4:

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Urticarias

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Contact urticarias

4.1

page: 71

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Urticarias

Contact urticarias

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cause basic lesion

Urticarial weals occurring within minutes of putting on surgical latex gloves. These weals can spread beyond the actual site of contact because this is an immunoallergic urticaria (specific IgE are sometimes present). Generalized urticaria with systemic symptoms can therefore occur: allergic rhinitis, conjunctivitis, asthma-like attacks, anaphylactic shock, etc.

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Latex contact urticaria

Contact urticarias

page: 72

alphabetical

Urticarias

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Prick test with latex

basic lesion

cause

Diagnosis of latex contact urticaria: the prick test is performed with a lancet, using incubation liquid from the suspected latex gloves.

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Provocative use test with latex gloves In cases of doubt (prick test difficult to interpret), a provocation test can be performed, if necessary with the suspected glove. This will always be done initially with a finger-stall, which is slipped onto a moistened finger for 10 min. The provocation test must always be done in a hospital environment.

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page: 73

cause

Contact urticarias

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Urticarias

Physical urticarias

4.2

page: 74

alphabetical

Urticarias

Physical urticarias

cause basic lesion

Drawing on the skin with a blunt tip produces a linear erythema with an oedematous component. The dermographism appears 5 to 10 min after the rubbing. It can be isolated or associated with chronic idiopathic urticaria.

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Dermographism

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Physical urticarias

page: 75

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Urticarias

cause basic lesion

Very itchy deep oedema occurring several hours (6 to 12 hours) after strong pressure on a precise area, e.g. on palmar side. Feet can be affected after walking, as can buttocks after prolonged sitting.

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Pressure urticaria

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page: 76

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Urticarias

cause basic lesion

Eruption triggered by cold: the application of an ice-cube for 3 to 10 min systematically reproduces an urticarial weal. Nevertheless, in the present case it would be appropriate to perform a second test to eliminate aquagenic urticaria (with immersion of one hand in water at ambient temperature).

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Cold urticaria

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page: 77

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cause basic lesion

This very rare variant of urticaria occurs within minutes on exposure to sunlight. The eruption can persist for three to four hours. Photobiological investigation very easily confirms the diagnosis (photosensitivity test positive with UVA and/or UVB).

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Solar urticaria

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Common urticarias (medicines, food, idiopathic)

4.3

page: 78

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Urticarias

Common urticarias (medicines, food, idiopathic)

cause basic lesion

Eruption of oedematous urticated weals which can coalesce into broad patches. Itching is constant and can prevent sleep. This urticaria can be the first sign of anaphylactic shock.

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Urticated weals

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cause basic lesion

Urticarial weals spread symmetrically over the body, most often blamed on medicines. Specific foods can sometimes trigger this type of urticaria (acute urticaria). Strawberries, shellfish, fish, certain cereals, milk, eggs, and some particular food additives are most frequently the cause. The diagnosis is based mainly on provocation tests (withdrawal and reintroduction of the suspected medicine or food).

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Papular urticaria

Common urticarias (medicines, food, idiopathic)

page: 80

alphabetical

Urticarias

cause basic lesion

The urticarial papules describe curlicues or geographical shapes. In this case, the cause would most often be a drug (aspirin, codeine, penicillin, etc.). Again, a withdrawal test with reintroduction, if appropriate, makes it possible to reach an exact diagnosis.

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Figured urticaria

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Urticarias

cause basic lesion

Not particularly itchy, deep urticaria mainly affecting the face (particularly eyelids and lips), the glottis, and even the larynx. This is an emergency which requires rapid therapeutic intervention (adrenaline and corticosteroids in particular). Iatrogenic causes are not uncommon.

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Hereditary angio-oedema

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cause basic lesion

Combination of urticaria with lesions of leucocytoclastic vasculitis. The urticarial lesions are more fixed than in classical urticaria. They last for 2 to 3 days and are frequently accompanied by joint pains and by fever. Reduced complement levels in blood are observed.

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Urticarial vasculitis

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page: 83

Chapter 5:

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Infectious viral diseases

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5.1

Herpes virus group

page: 84

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Herpes virus group

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Multiple vesicles arranged in a cluster on an erythematous background. The lesions are usually painful and in most cases preceded by a burning or itching sensation. The vesicles rupture spontaneously after a few days and drying occurs later. Recurrences are typical (recurrent herpes), usually at the same site.

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Herpes of the face

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Type I herpes

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page: 85

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There are lesions which correspond to two stages of development: vesicles on an erythematous base on the prepuce (recent attack) and black crusts on the shaft (old attack). The lesions are itching and painful. The diagnosis is confirmed with liquid from a vesicle: smear for immunological diagnostics with the aid of monoclonal antibodies and culture.

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Herpes of the penis

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Type II herpes (genital)

Herpes virus group

page: 86

alphabetical

Infectious viral diseases

Varicella and herpes zoster are associated with infection by the virus Herpes varicellae.

basic lesion

Vesicles on a background of healthy skin or surrounded by an erythematous ring, distinctly separated from each other, whose contents become cloudy secondarily.

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Varicella

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Varicella

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page: 87

continued

basic lesion

The central umbilication is classical. They develop to form an adhesive crust which sometimes leaves a depressed scar when it detaches.

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Herpes virus group

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cause basic lesion

Herpes zoster is associated with infection by the virus Herpes varicellae. Vesiculobullous dermatosis preceded and very often accompanied by considerable pain (especially in old people). The lesions are strictly unilateral and correspond to the tract of a nerve root. In the present case an intercostal nerve is involved ("fiery half-girdle").

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Zoster of the trunk

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page: 89

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cause basic lesion

In the present case the topography of the lesions makes it possible to say that two branches are affected by the infectious process: the ophthalmic branch and the superior maxillary branch. The third branch, the inferior maxillary, is spared. The presence of vesicles on the nostril shows that the nasociliary nerve is involved.

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Ophthalmic nerve zoster

5.2

Papillomavirus group

page: 90

alphabetical

Infectious viral diseases

Papillomavirus group

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The papillomaviruses are responsible for the occurrence of various types of benign tumour, viral warts.

basic lesion

Small greyish keratotic tumours, rough to the touch, on the backs of the fingers. Common warts are contagious and autoinoculable.

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Common warts

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Papillomavirus group

page: 91

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cause

These warts are mainly located on the face and on the back of the hands or fingers. They are orange very slightly raised papules.

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Plane warts

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Plane warts

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Papillomavirus group

continued

basic lesion

cause

The linear disposition is typical (Koebner's phenomenon caused by autoinoculation along scratch lines).

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page: 93

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cause basic lesion

Fleshy reddish formations on the genital organs. Condylomata acuminata are contagious (sexually transmitted disease) and can spread rapidly. The maceration is sometimes considerable.

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Condylomata acuminata

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page: 94

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Distinctly demarcated keratotic formation which is often deeply embedded in the skin of the sole. The disappearance of dermatoglyphics all over the surface of plantar warts is typical and makes it possible to distinguish this lesion from a corn. A single plantar wart is classically known as myrmecia.

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Plantar wart

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page: 95

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cause basic lesion

Juxtaposition of numerous plantar warts forming a hyperkeratotic patch by spreading by degrees. These mosaic plantar warts are often painful (sensitivity to pressure during walking).

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Mosaic warts

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page: 96

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cause basic lesion

Small pedunculate papilloma mainly affecting the face (nose, side of the neck, and cheeks). Horny filiform warts are typically found in men (shaving, especially with a razor rather than an electric shaver, contributes to dissemination).

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Horny filiform wart

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Epstein-Barr virus

page: 97

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Epstein-Barr virus

cause basic lesion

Appearance of fine whitish striations on the sides of the tongue. Oral hairy leucoplakia is most often encountered in homosexual men suffering from AIDS. The term "hairy" is purely descriptive. The hairy appearance is associated with linear hyperplasia.

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Hairy leucoplakia

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Pox and parapox virus groups

page: 98

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Small round papule with a smooth surface, often shiny, a few millimetres in diameter. There is often a small central depression (crater, often filled with creamy whitish material). These lesion most frequently affect children and can be secondarily accompanied by eczema around the lesion. Molluscum contagiosum is caused by a poxvirus.

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Molluscum contagiosum

Pox and parapox virus groups

page: 99

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cause basic lesion

Illustration of the phase of dissemination of the lesions. The topographical predilection for the axilla is characteristic. In some cases the mollusca contagiosa can become inflamed and there can be a superimposed infection. In adults molluscum contagiosum is often found in the genital area. An immunological status check is indispensable in the case of very numerous lesions (especially if found on the face).

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Multiple mollusca contagiosa

Pox and parapox virus groups

page: 100

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cause basic lesion

Red to violet pseudovesicular papule appearing on the dorsal face of a finger. The incubation period varies from three days to two weeks after contact with a sick animal (usually sheep). Regression without complications in about two weeks. A superimposed bacterial infection is not uncommon. ORF is caused by a parapoxvirus.

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ORF

5.5

Other viruses

page: 101

alphabetical

Infectious viral diseases

Other viruses

cause basic lesion

Maculopapular "butterfly-wing" eruption of the face giving a puffy appearance, like "butterfly wings". The biphasic development of the lesions on the face is typical.

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Erythema infectiosum

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page: 102

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basic lesion

After the second bout there are often numerous pink polycyclic or circinate maculopapules, describing curlicues on the limbs. The eruption disappears in about ten days and is caused by Parvovirus B19.

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Other viruses

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Other viruses

page: 103

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cause basic lesion

Maculopapular eruption, very pronounced on the face. Enanthema is also present. Some healthy skin areas can always be seen. There is often a superimposed ENT bacterial infection and injection of the conjuctivae. Measles is caused by a paramyxovirus.

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Measles

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Other viruses

page: 104

alphabetical

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cause basic lesion

Intraoral enanthema of the anterior part of the mouth, with small greyish vesicles which rupture very rapidly. The pain caused can make it difficult to eat.

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Hand-foot-and-mouth-disease

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Other viruses

page: 105

alphabetical

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basic lesion

Appearance of small oval vesicles about 3 to 4 millimetres in diameter on the hands and feet. The vesicles are greyish-white and surrounded by an erythematous halo.

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continued

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Hand-foot-and-mouth-disease

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Other viruses

page: 106

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There is a vaguely painful sensation. Disappearance is rapid; disseminated lymphadenopathy can be present. Similar lesions are sometimes found on the buttocks. The condition is generally caused by the Coxsackie A16 virus. Other coxsackie viruses may also be responsible.

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continued

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Hand-foot-and-mouth-disease

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page: 107

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cause basic lesion

Relatively modest erythematous macular eruption accompanied by suboccipital lymphadenopathy with considerable swelling. The pale pink colour and the unobtrusive effect on general health are other features to be borne in mind. In adults and adolescents the symptoms are often more prominent (fever and more pronounced rash). The pathogen is a togavirus.

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Rubella

5.6

Signs of AIDS on skin and mucosa

page: 108

alphabetical

Infectious viral diseases

Signs of AIDS on skin and mucosa

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Necrotic herpes zoster

basic lesion

cause

Multiple ulcers developing from necrotic patches. These ulcerated lesions have spread considerably.

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Signs of AIDS on skin and mucosa

Necrotic herpes zoster

continued

basic lesion

cause

After several weeks, the ulcerated lesions have left slightly atrophic cicatrized patches.

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Infectious viral diseases

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Signs of AIDS on skin and mucosa

page: 110

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Seborrhoeic dermatitis

basic lesion

cause

Seborrhoeic dermatitis, often severe and resistant to conventional treatments, can be seen in the course of an HIV infection. In the present case the involvement of the whole nasal pyramid was the first sign of HIV infection.

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Signs of AIDS on skin and mucosa

page: 111

alphabetical

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cause basic lesion

In quite a number of cases prurigolike lesions (excoriated nodules) accompanied (or caused) by diffuse pruritus are observed. The involvement of the trunk is relatively typical.

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Prurigo

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Signs of AIDS on skin and mucosa

page: 112

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cause basic lesion

The dentogingival junction is the site of a purulent erythema (presence of fusiform and spiral bacteria). This periodontitis is painful and shows no tendency to regress spontaneously.

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Gingivitis

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Signs of AIDS on skin and mucosa

page: 113

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cause basic lesion

Very numerous mollusca on the face, sometimes with a few lesions which are haemorrhagic in appearance, can be seen in AIDS. The mollusca are generally very deeply embedded in the skin. Curettage is relatively difficult. The mollusca show a marked tendency to multiply.

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Molluscum contagiosum

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page: 114

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cause basic lesion

Purplish angiomatous papular lesion. The preferred involvement of the face is typical in AIDS patients. In the present case Kaposi's nodules are observed side by side with mollusca contagiosa.

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Kaposi's sarcoma

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page: 115

continued

basic lesion

Kaposi's nodules can occur in large numbers all over the skin. These nodules keep distinct margins with angular edges. Here again the violet colour is characteristic. The nodules are generally completely painless.

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Signs of AIDS on skin and mucosa

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Infectious viral diseases

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page: 116

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cause basic lesion

Abnormally large or rapid spread of condylomata acuminata must always lead to a suspicion that the patient is seropositive for HIV. In the present case the condylomata spread all over the vulva and into the vaginal canal.

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Condylomata acuminata

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page: 117

Chapter 6:

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Bacterial infections diseases

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6.1

Impetigo

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Bacterial infections diseases

Impetigo

cause basic lesion

Bullae with cloudy contents, often surrounded by an erythematous halo. These bullae rupture easily and are rapidly replaced by extensive crusty patches. Bullous impetigo is classically caused by Staphylococcus aureus .

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Bullous impetigo

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Impetigo

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Bacterial infections diseases

basic lesion

ß-Haemolytic streptococcus is most frequently found in this type of impetigo.

cause

Erythematous patches covered by a yellowish crust. Lesions are most frequently around the mouth. Lesions around the nose are very characteristic and require prolonged treatment.

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Non-bullous impetigo

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page: 120

alphabetical

6.2

Ecthyma

Ecthyma

basic lesion

cause

Slow and gradually deepening ulceration surmounted by a thick crust. The usual site of ecthyma are the legs. After healing there is a permanent scar. The pathogen is often a streptococcus. Ecthyma is very common in tropical countries.

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page: 121

alphabetical

6.3

Folliculitis

Folliculitis

basic lesion

cause

Inflammatory papule with a follicular pustule at its centre. The pathogen is usually a staphylococcus. Folliculitis is frequently multiple and classically located on the buttocks, thighs, or the face.

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page: 122

alphabetical

6.4

Furuncle (BOIL)

Furuncle (BOIL)

basic lesion

cause

Acute deep folliculitis starting with a painful erythematous papule with the appearance of a central pustule. After spontaneous or induced evacuation of the pus, the furuncle often leaves a permanent scar. The pathogen is Staphylococcus aureus .

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page: 123

alphabetical

6.5

Carbuncle

Carbuncle

basic lesion

cause

By definition, carbuncles result from the coalescence of several juxtaposed furuncles. A large painful lump is strewn with small pustules which emerge on the skin surface.

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page: 124

Erysipelas

basic lesion

Hot, painful, oedematous erythematous patches, accompanied by fever and malaise, typically caused by a streptococcus. Erysipelas can affect the face, and in this case the border against healthy skin is very distinct and raised: the "step" sign.

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6.6

Erysipelas

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Bacterial infections diseases

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On the leg one observes extensive wide patches identical with those on the face but having a less accentuated margin. Again, the general health is affected, and there is always fever. A mixed infection is found in most cases (gram positive and/or gram negative bacteria). There is often a portal of entry, e.g. a lesion between the toes or a wound caused by trauma.

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Erysipelas

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page: 125

cause

Erysipelas

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page: 126

alphabetical

6.7

Orbital cellulitis

Orbital cellulitis

basic lesion

cause

Deep retro-orbital infection manifests itself on the skin with periorbital oedema accompanied by malaise and fever. This is evidently a serious condition, given the possibility of spreading towards the cavernous sinus.

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page: 127

Septic emboli

basic lesion

Small erythematous pustular lesions occurring simultaneously in a number of places. The general context depends on the starting point of these septic emboli (cardiac involvement in rheumatic fever, gonorrhoea in the process of dissemination, etc.).

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6.8

Septic emboli

cause

Bacterial infections diseases

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page: 128

alphabetical

6.9

Borrelia infections

Borrelia infections Erythema chronicum migrans or lyme disease

basic lesion

cause

Broad erythematous patch spreading outwards with a false appearance of healing at the centre.

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Erythema chronicum migrans or lyme disease continued

basic lesion

Sometimes a small scar is found in the middle (trace of a tick bite). Erythema chronicum migrans is caused by Borrelia infection.

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Borrelia infections

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Borrelia infections

page: 130

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In some cases the Borrelia infection is clinically recognized by the presence of one or more pasty nodules, mainly on uncovered parts of the body, most typically on earlobes. This type of "pseudolymphoma" is also one of the Borrelia diseases. One can include this lesion among the forms of the old "lymphocytoma benigna cutis".

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Borrelia pseudolymphoma

page: 131

alphabetical

6.10

Proteus infection

Proteus infection

basic lesion

cause

In rare cases, if untreated contused lesions are present, a gram-negative microorganism such as Proteus or Pseudomonas can cause necrosis of the distal extremity of a finger.

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6.11

Cat-scratch disease

Cat-scratch disease

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cause

More or less fluctuant nodules with ulceration and central crust, accompanied by lymphadenopathy with considerable swelling.

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Cat-scratch disease

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Cat-scratch disease

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basic lesion

cause

The young patient was scratched by his cat a few weeks previously.

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alphabetical

6.12

Intertrigo

Intertrigo

basic lesion

cause

Glazed erythematous patches with the appearance of "pages of a book", centred on the base of a large fold. Maceration and infection with common microorganisms are typical.

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Cutaneous tuberculosis

page: 135

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Cutaneous tuberculosis

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cause

Large reddish-yellow lesion affecting the face and the earlobe. False appearance of healing at the centre.

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Lupus vulgaris

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Lupus vulgaris

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page: 136

continued

basic lesion

Vitropression reveals characteristic orange-red coloration, which dermatologists at the beginning of the century compared to "barley sugar", a delicacy which has now gone out of fashion.

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Cutaneous tuberculosis

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Bacterial infections diseases

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Cutaneous tuberculosis

page: 137

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Scofuloderma

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Chronic tuberculous cervical lymphadenopathy with skin ulceration.

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page: 138

Complication of BCG vaccination

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Non-specific abscess formation after BCG vaccination. This complication of BCG vaccination is generally the result of an injection made too deeply.

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Cutaneous tuberculosis

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Atypical mycobacterial infections Infection with mycobacterium marinum This condition is found mainly in fish fanciers (fish-tank disease) and classically appears in the form of a chain of nodules spaced like rosary beads, extending along the line of lymphatic drainage. These are more or less keratotic papulonodular lesions and/or ulcers. There is generally little pain. Deep biopsy with culture in a suitable medium very easily reveals the mycobacterium.

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page: 139

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6.14

Atypical mycobacterial infections

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Bacterial infections diseases

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page: 140

Infection with mycobacterium marinum continued

basic lesion

The papulonodules can be single or multiple. The latter form of the mycobacterial infection is sometimes known as sporotrichoid.

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Atypical mycobacterial infections

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Bacterial infections diseases

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Infection with mycobacterium fortuitum or chelonae

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cause

Abscess and violet nodules occurring a few weeks after repeated injections as part of mesotherapy (in the treatment of "cellulitis").

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6.15

Corynebacterium infections

page: 142

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Bacterial infections diseases

Corynebacterium infections

cause basic lesion

Broad and distinctly demarcated brownish or buff macule, with rounded margins, usually symmetrical and affecting either the groins or the axillae. These lesions are homogeneous and finely squamous. The pathogen is Corynebacterium minutissimum . Examination in Wood's light reveals coral-red fluorescence.

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Erythrasma

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page: 143

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cause basic lesion

This is a bacterial infection caused by corynebacteria. The axillary hairs are surrounded by small yellowish nodules corresponding to colonies of bacteria. There is little in the way of subjective symptoms. The sweat sometimes becomes yellowish.

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Trichomycosis axillaris

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page: 144

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Small serpiginous erosions of the horny layer with a punched-out appearance, mainly found on weight-bearing areas of the soles and causing an interruption in footprints. An associated plantar hyperhidrosis is often present. The erosions correspond to areas of desquamation in a block of the horny layer invaded by corynebacteria.

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Pitted keratolysis

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page: 145

Chapter 7:

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page: 146

Syphilis Syphilitic chancre (primary sore)

basic lesion

Ulceration with erosion situated on the glans penis or sheath. Distinctly palpable induration. Considerable swelling of inguinal lymph nodes, usually unilateral.

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7.1

Syphilis

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Treponematoses and other sexually transmitted diseases

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Syphilitic chancre (primary sore)

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page: 147

continued

basic lesion

The characteristics of female chancre are identical with those in the male. In women the chancre is often accompanied by considerable oedema of the labia majora.

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Syphilis

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Treponematoses and other sexually transmitted diseases

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page: 148

Secondary syphilis (macular syphilid)

basic lesion

Occurring about six weeks after the start of the chancre, secondary syphilis appears in the form of pink oval macules with little or no scaling and no itching. These macules are located mainly on the trunk.

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Syphilis

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Treponematoses and other sexually transmitted diseases

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Syphilis

page: 149

alphabetical

Treponematoses and other sexually transmitted diseases

cause basic lesion

Dull red, sometimes brownish, very distinctly indurated papules, which are not itchy, located on the trunk and on the proximal regions of the limbs.

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Late secondary syphilis

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Syphilis

page: 150

alphabetical

Treponematoses and other sexually transmitted diseases

cause basic lesion

Slightly reddish macules with peripheral desquamative collarette (Biett's collarette). These papular syphilids occur four to twelve months after the chancre.

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Papular syphilids

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Syphilis

page: 151

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Treponematoses and other sexually transmitted diseases

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Genital gonorrhoea

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cause

Diffuse redness of the glans, purulent urethral discharge, considerable dysuria, pollakiuria. Presence of two mollusca contagiosa, equally sexually transmitted.

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page: 152

Chapter 8:

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Mycoses

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8.1

page: 153

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Mycoses

Dermatophytoses

cause basic lesion

Round or oval lesion, as in the present case, with a distinctly raised margin, sometimes with fine vesicles, sometimes very scaly. There is often a false appearance of healing at the centre. These round lesions are generally slightly scaly. Pruritus is not always present as a subjective symptom. The lesions can be single.

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Tinea corporis

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Tinea corporis

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Dermatophytoses

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basic lesion

cause

The lesions can be multiple. The pathogen is generally Microsporum canis, or Trichophyton rubrum.

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Mycoses

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Mycoses

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cause

The dermatophytosis has the same appearance as on glabrous skin, but can assume an impressive clinical picture owing to it's spread.

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Tinea faciei

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Tinea faciei

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Dermatophytoses

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Mycoses

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cause

The dermatophytosis can also assume a more or less atypical clinical picture owing to late diagnosis or unsuitable topical therapy with corticosteroids.

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Dermatophytosis of the inguinal fold (also called dhobi itch and Hebra's eczema marginatum). This dermatophytosis affects men more frequently than women. A very distinct vesicular border circumscribes a central red, sometimes brownish, central region, which is always scaly. The lesion typically spreads towards the inner thigh.

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Tinea cruris

Dermatophytoses

page: 158

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This condition affects the palms, most frequently on one hand. There is no substantial hyperkeratosis. An active margin may be noticeable at the wrist. Association with athlete's foot or eczema marginatum is typical, and it is a good idea to persevere in looking for this. Scraping with a curette generally yields plenty of horny, brittle, powdery material.

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Tinea manuum

page: 159

Tinea manuum

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Dermatophytoses

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basic lesion

cause

It is characterized by diffuse redness and dryness with floury accentuation of flexural creases of the palms.

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Mycoses

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Dermatophytoses

page: 160

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Mycoses

cause basic lesion

Fissured and scaly intertrigo of the space between the fourth and the fifth toes. There is often a small painful crack running along the base of the fold.

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Tinea pedum (athlete's foot)

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Dermatophytoses

page: 161

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Mycoses

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basic lesion

cause

Sometimes the whole area is eroded, which is a sign of microbial infection.

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Tinea pedum (athlete's foot)

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Dermatophytoses

page: 162

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Mycoses

basic lesion

The dermatophytosis can extend to the sole, which it affects more or less extensively. In some cases in which tinea manuum is associated with tinea pedis, three of the four limbs are affected (e.g. one hand and two feet).

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Tinea pedum (athlete's foot)

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The scalp is attacked by a dermatophyte. Children are affected most often. Large plaque of alopecia, presence of numerous short broken hairs, on a greyish and scaly base. The pathogen is most frequently Microsporum canis. Ringworm is characteristic of the prepubescent period: it is distinguished from alopecia or pseudo-alopecia by its floury appearance.

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Tinea capitis or ringworm

Dermatophytoses

page: 164

alphabetical

Mycoses

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Kerion

basic lesion

cause

Crusty and well demarcated suppurative patch sometimes tumour-like. Most typical site is the scalp in the child.

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Kerion

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Mycoses

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cause

Another most typical site is the beard in the adult.

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Kerion

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Dermatophytoses

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basic lesion

cause

The lesion evolves into a definitive scar. The pathogen is Trichophyton mentagrophytes or Trichophyton verrucosum.

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Mycoses

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page: 167

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Mycoses

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Onychomycosis due to dermatophytes

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cause

Thickened and opaque nail, distal onycholysis. The nail becomes brittle. There is no associated paronychia.

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Onychomycosis due to dermatophytes

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basic lesion

More rarely, dermatophytic onychomycosis involves the superficial layer of the nail plate and appears in the form of small opaque whitish patches which are well demarcated (appearance of leuconychia). The surface becomes more brittle as a result.

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Dermatophytoses

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Mycoses

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Candidiasis

8.2

page: 169

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Mycoses

Candidiasis

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Thrush is the classical form of intraoral candidiasis, characterized by a whitish coating of creamy consistency covering bright red areas of erosion. Scraping with the curette removes the coating and exposes the erosion patches. The inner cheek surface and the tongue are affected. The surrounding mucosa is inflamed and there is a considerable burning sensation. The pathogen is Candida albicans.

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Thrush

Candidiasis

page: 170

alphabetical

Mycoses

cause basic lesion

Fissures, which are most frequently symmetrical, localized at the corners of the lips and surrounded by small impetigo-like crusts. Edentulous patients or patients with badly fitting dentures are most frequently affected. A superimposed bacterial infection is very common.

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Angular cheilitis

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Candidiasis

page: 171

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Mycoses

cause basic lesion

More or less symmetrical exudative erythematous axillary patches with small satellite lesions. A peripheral desquamative collarette is often present.

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Candidal intertrigo

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Candidiasis

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Candidal intertrigo

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Candidiasis

page: 173

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Mycoses

cause basic lesion

Symmetrical involvement of the external genitals with peripheral desquamative collarette and small punctiform erythematous satellite lesions which are sometimes somewhat pustular. Itching is generally severe. There is frequently an associated whitish leucorrhoea.

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Candidal vulvovaginitis

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Candidiasis

page: 174

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Mycoses

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Candidal balanitis

basic lesion

cause

Glazed erythema surrounded by a fine whitish border, affecting the glans and the neck of the penis. Relatively intense burning. Recurrences are common.

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Candidal paronychia and subungual infection Thickened, brittle, and yellowish nail, accompanied by an inflamed nail fold which discharges a purulent exudate on pressure. Pain is typical. Some cases of candidal paronychia are preceded by irritant dermatitis, most frequently to vegetable or animal proteins (protein contact dermatitis).

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page: 175

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Candidiasis

basic lesion

Mycoses

Candidiasis

page: 176

alphabetical

Mycoses

cause basic lesion

Wide glazed erythematous patch over the whole area of genitals and buttocks with satellite lesions. The condition classically starts at the base of the folds (inguinal folds, cleft of the buttocks or anal region).

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Napkin candidiasis (infant)

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8.3

page: 177

alphabetical

Pityriasis versicolor

Pityriasis versicolor

basic lesion

cause

Small, well-demarcated buff or brownish patches located mainly on the trunk or the neck. Pruritus is moderate or absent.

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Mycoses

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Pityriasis versicolor

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page: 178

continued

basic lesion

Scraping with a curette reveals a scale becoming detached from a mass of scales: chip sign. The depigmented form can either be scaly from the beginning and thus contagious, or residual after exposure of pigmented pityriasis versicolor to the sun.

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Pityriasis versicolor

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Mycoses

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In this case it is not contagious and represents only the aftermath of an old pityriasis versicolor after treatment. In cases of doubt, mycological examination reveals the presence of short mycelial filaments accompanied by colonies of small round spores (Malassezia furfur). Wood's light examination reveals the presence of a yellowish fluorescence.

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Pityriasis versicolor

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page: 179

cause

Pityriasis versicolor

basic lesion

Mycoses

Deep fungal infections

8.4

page: 180

alphabetical

Mycoses

Deep fungal infections

cause basic lesion

Multiple violet papulonodular lesions developing along the lines of lymphatic drainage, associated with infection with Sporothrix schenkii. The limbs are most frequently affected.

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Sporotrichosis

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page: 181

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Mycoses

cause basic lesion

Severe inflammatory swelling located most frequently on the foot, exuding a purulent material containing grains through fine breaks. The pathogens can be either eumycetes or actinomycetes.

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Mycetoma (Madura foot)

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page: 182

Chapter 9:

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Parasitic diseases – arthropods

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page: 183

Human scabies

basic lesion

Parasitic disease caused by Sarcoptes scabiei. Blackish burrows from 5 to 15 mm in length, ending in a vesicle at one end ("mite hill"). The sides of the fingers and the anterior surfaces of the wrist are sites of predilection. Numerous marks of excoriation, sometimes accompanied by fine more or less translucent vesicles spread all over the skin.

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9.1

Human scabies

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Parasitic diseases – arthropods

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Human scabies

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Human scabies

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Parasitic diseases – arthropods

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cause

These excoriations are mainly the sign of very severe itching in the evening and at night.

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Human scabies

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page: 185

continued

basic lesion

Scabies nodules: very distinctly infiltrated, extremely itchy reddish nodules in the axillae, on the scrotum, and on the penis, persisting even after successful treatment.

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Human scabies

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Parasitic diseases – arthropods

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Human scabies

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Human scabies

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cause

In children the lesions usually affect the feet: numerous extremely itchy excoriated papules.

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Parasitic diseases – arthropods

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9.2

Animal scabies

Animal scabies

basic lesion

cause

Numerous small itchy papules spread all over the skin, which regress spontaneously. There are no burrows. The patient's pet (cat or dog) is typically found to be infested.

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Parasitic diseases – arthropods

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9.3

Pediculosis (head lice)

page: 188

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Parasitic diseases – arthropods

Pediculosis (head lice)

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cause

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Wide impetigo-like patch at the nape of the neck caused by scratching, associated with very severe undiagnosed infestation.

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Pediculosis (head lice)

Pediculosis (head lice)

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Parasitic diseases – arthropods

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cause

Area of attachment of a nit to a hair.

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page: 190

Crab lice (pubic lice)

basic lesion

Excoriations and presence of louse eggs firmly attached to the pubic hairs. There are also crab lice (Phthirius pubis) grasping the public hairs. On the body, relatively discrete bluish grey macules (maculae caerulae) can sometimes be found.

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9.4

Crab lice (pubic lice)

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Parasitic diseases – arthropods

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Crab lice (pubic lice)

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cause

These blue-grey macules correspond to the release of toxins by the crab louse in the course of successive bites.

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9.5

Insect bites

page: 192

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Parasitic diseases – arthropods

Insect bites

cause basic lesion

Immunological reactions to bites by harvest mites (larvae of Trombiculidae which feed on blood). Small itchy lesions, sometimes in a line, located anywhere on the skin, with predilection for constricted areas. The lesions sometimes rise to a point in the centre.

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Trombiculiasis

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Insect bites

page: 193

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Trombiculiasis

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Infantile papular urticaria (strophulus) Occurring mainly in children, this type of papular urticaria occurs in the form of numerous small erythematous papules, sometimes with fine vesicles. The lesions are found mainly on the legs, are extremely itchy, and very likely to be excoriated. Sometimes a linear disposition is seen, which makes the diagnosis much more obvious. Infantile papular urticaria is caused by an ectoparasite with a cat or dog host. Basic Lesions:

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page: 194

cause

Insect bites

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Parasitic diseases – arthropods

Insect bites

page: 195

alphabetical

Parasitic diseases – arthropods

cause basic lesion

Large inflammatory papules in a linear disposition. There is a distinct central acumination. Infestation is usually via a pet (cat or dog), which acts as the carrier.

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Flea bites

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Flea bites

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Insect bites

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cause

In some cases the lesions become frankly bullous and even haemorrhagic.

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9.6

Leishmaniasis

Leishmaniasis

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cause

Large encrusted papular lesion surrounded by an inflammatory rim. There is no associated pain or lymphadenopathy. The course is chronic and the lesion is resistant to conventional antiseptic treatments.

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continued

basic lesion

It is a protozoan infection caused by a species of Leishmania. The carrier is a Phlebotomus fly, which explains why in most cases the lesions of leishmaniasis are found on uncovered areas (especially the face).

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Leishmaniasis

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Leishmaniasis

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Leishmaniasis

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basic lesion

cause

After a few months the lesion subsides, leaving a scar of variable visibility.

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page: 200

Larva migrans (creeping eruption)

basic lesion

Inflammatory serpiginous line ending in a small, extremely itchy papule. Larva migrans is caused by a larva of an Ancylostoma species (hookworm) which migrates about 1 cm per day, thus extending the line of inflammation. In humans contact usually occurs on the beach (soil polluted with animal excreta). Cutaneous larva migrans is found mainly on the feet and the buttocks.

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9.7

Larva migrans (creeping eruption)

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Parasitic diseases – arthropods

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basic lesion

cause

Larva migrans (creeping eruption)

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Larva migrans (creeping eruption)

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page: 202

Tungiasis (chigger)

basic lesion

Itchy inflammatory nodule with a small blackish opening at the centre, found in the periungual region of a toe. Secondary superinfection (abscess formation) may be present. Tungiasis is caused by a flea which lives on blood: Tunga penetrans.

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9.8

Tungiasis (chigger)

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Tungiasis (chigger)

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Tungiasis (chigger)

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basic lesion

cause

Infestation typically occurs on the feet (walking barefoot in areas where it is endemic, especially Africa and Central America).

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page: 204

Chapter 10:

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Psoriasis

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Clinical aspects

10.1

page: 205

alphabetical

Psoriasis

Clinical aspects Psoriasis vulgaris

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Erythematous form

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cause

Very extensive psoriasis. Large confluent patches, mainly erythematous, covered in fine scales.

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Scaly erythematous form

basic lesion

Psoriasis on the knees. Well demarcated scaly erythematous patches. Thick white scales with a shiny micaceous appearance.

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Clinical aspects

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Psoriasis

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Plaster-like psoriasis Extended psoriatic lesions on the trunk and the arms. In the present case the scales, which are thick and adherent, mask the erythema which appears here and there like a thin border at the edge of the lesions. The appearance of the scales is such that they are often referred to as cretaceous psoriasis or, more picturesquely "plaster-like scales".

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Psoriasis vulgaris

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page: 207

cause

Clinical aspects

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Psoriasis

page: 208

Psoriasis vulgaris

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Clinical aspects

continued

Characteristic clinical symptoms

basic lesion

cause

Patches resemble candle wax.

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Psoriasis

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Psoriasis vulgaris

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Characteristic clinical symptoms

basic lesion

cause

Patches are bleeding after curettage.

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Psoriasis

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Psoriasis vulgaris

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Psoriasis

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Guttate psoriasis

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cause

Guttate psoriasis consists of innumerable small scaly erythematous patches, a few millimetres across, which in the present case are distributed all over the skin.

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Psoriasis vulgaris

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Guttate psoriasis

basic lesion

cause

In many cases it is an eruptive psoriasis of childhood or adolescence.

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Psoriasis

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Psoriasis vulgaris

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Psoriasis

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Koebner's phenomenon (isomorphic reaction)

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cause

Psoriatic lesions appear around a surgical scar.

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alphabetical

Psoriasis

basic lesion

Pustular psoriasis of the flexor surface of the forearm. Large erythematous patch with distinct margins, strewn with a scatter of flattened yellowish-white pustules arranged in confluent clusters.

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Body

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Psoriasis vulgaris

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continued

Feet

basic lesion

Plantar pustular psoriasis. Isolated pustules appear on a scaly erythematous base with distinct borders.

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Psoriasis

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continued

Feet

basic lesion

The most recent yellowish-white pustules are slightly raised, whereas the older pustules are brown and embedded in the horny layer of the epidermis.

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Clinical aspects

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Psoriasis

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Clinical aspects

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alphabetical

Psoriasis

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Psoriatic erythroderma

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cause

The erythrodermic psoriasis has spread all over the body.

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Psoriasis

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Psoriatic erythroderma continued

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cause

The erythrodermic psoriasis has spread all over the body without intervals of healthy skin.

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10.2

page: 218

alphabetical

Psoriasis

Particular local forms

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Palmoplantar psoriasis

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cause

Palmar psoriasis. Scaly erythematous patches with distinctly rounded contours. The covering scales are thick and nacreous.

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Psoriasis

cause basic lesion

Inverse psoriasis of an axilla. The psoriatic eruption consists of a continuous plaque which is bright red, shiny, smooth, and not very scaly, with a well-circumscribed margin.

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Flexural psoriasis

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Psoriasis

cause basic lesion

The picture, which is very complete, includes distal onycholysis with yellow coloration, cup-shaped depressions in the central area, and advanced disintegration of the nail plate in the proximal area. In addition, classical psoriatic lesions have invaded the whole of the nail fold.

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Psoriasis of the nails

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Psoriasis

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cause

The round, scaly erythematous patches spread beyond the hairline to invade the cervical region.

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Psoriasis of the scalp

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Psoriasis of the face (seborrhoeic psoriasis)

basic lesion

Psoriasis of the face is rare and is usually found predominantly in the seborrhoeic regions: wings of the nose, area between the eyebrows, hairline. It is often called "seborrhoeic psoriasis".

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Particular local forms

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Psoriasis

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Psoriasis

basic lesion

Erythematous and slightly glazed plaques with distinct margins, scattered over the upper surface of the tongue. The picture is quite similar to that described by the term geographical tongue (or benign migratory glossitis or lingual erythema migrans).

cause

1. Psoriasis of the tongue

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Mucosal psoriasis

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continued

2. Psoriasis of the glans penis

basic lesion

Large red and well-circumscribed plaques, neither infiltrated nor scaly, with a chronic course. They present problems of differential diagnosis, as they have to be distinguished from balanitis of other origins.

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Particular local forms

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Psoriasis

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Chapter 11:

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11.1

Pityriasis rosea

page: 226

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Other skin diseases

Pityriasis rosea

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cause

picture

The eruption consists of pink oval patches measuring 1 to 3 cm in diameter, with fine scaling in a peripheral collarette. The initial lesion, looking like an oval medallion, can usually be recognized by its larger size (diameter 5 to 6 cm) and its accentuated margin.

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Pityriasis rosea

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Pityriasis rosea

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basic lesion

cause

Its oblique orientation on the trunk is characteristic.

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Parapsoriasis Pityriasis lichenoides ("guttate parapsoriasis")

basic lesion

The polymorphic eruption is spread over the trunk and the limbs. It consists of red or brownish and more or less scaly maculopapular lesions. The characteristic feature is a brownish macule covered with an adherent scale, which detaches in one piece.

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11.2

Parapsoriasis

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Other skin diseases

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Parapsoriasis

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Other skin diseases

cause basic lesion

The eruption affects the trunk and the limbs, it is polymorphic: papulopustular lesions, necrotic, often haemorrhagic lesions, crusts, varioloid scars.

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Varioloid parapsoriasis

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Parapsoriasis

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Other skin diseases

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basic lesion

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Varioloid parapsoriasis

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page: 231

Chronic superficial scaly dermatitis (digitate dermatosis)

basic lesion

The lesions are oval, 2 to 5 cm in diameter, well-circumscribed, flat and yellowish pink with fine scaling. These patches are disposed in lines, the position of which is fairly stereotyped: slanting along the ribs on the trunk, longitudinal on the limbs.

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Parapsoriasis

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Premycotic or prereticulotic eruption with large plaques

basic lesion

The lesions consist of wide plaques (10 to 20 cm in diameter) located on the trunk and the base of the limbs. Their appearance is polymorphic: sepia-coloured scaly erythematous plaques, atrophic or even poikilodermal lesions.

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Parapsoriasis

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Lichen planus Simple cutaneous lichen planus

basic lesion

The basic lesion is a firm reddishviolet polygon. The surface, which has a sheen in oblique illumination, is covered with fine greyish striations known as Wickham's striae.

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11.3

Lichen planus

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Lichen planus

Simple cutaneous lichen planus continued

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cause

One of the preferred sites is the flexor surface of the forearm.

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Lichen planus

Simple cutaneous lichen planus continued

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cause

Papules may appear along the excoriations caused by scratching (Koebner's phenomenon).

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cause basic lesion

The lesions are white and reticulated. Their preferred site is the tongue and the lower posterior part of the cheeks ("fern-leaf" appearance).

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Oral lichen planus

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Oral lichen planus

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Lichen planus

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Other skin diseases

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cause

A rare form is erosive lichen planus: painful red ulcerations with no tendency towards spontaneous healing. The ulcers are surrounded by a lichen-like whitish border.

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Lichen planus

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cause basic lesion

The lesions are oval or coalescent, infiltrated, and pink or violet in colour. Their surface is hyperkeratotic. The skin disease classically affects the front of the legs.

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Hypertrophic lichen planus

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continued

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Hypertrophic lichen planus

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Lichen planus

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alphabetical

Other skin diseases

basic lesion

cause

Dorsal pterygium and flaps of nail at the sites.

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Lichen planus of the nails

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alphabetical

11.4

Graft versus host disease (GVHD)

Graft versus host disease (GVHD)

basic lesion

cause

In the subacute stage the graft's reaction against the host can appear as a lichenoid eruption. The lesions are spread all over the skin.

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Graft versus host disease (GVHD)

Graft versus host disease (GVHD) continued

basic lesion

cause

The lesions are spread all over the skin and can involve the mucosa.

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alphabetical

11.5

Lichenification

Lichenification

basic lesion

cause

Well-demarcated thick itchy hyperkeratotic patch on the ankle, forming a grid of scratch lines. The term neurodermatitis is sometimes used to describe this phenomenon.

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alphabetical

11.6

Subacute prurigo

Subacute prurigo

basic lesion

cause

The excoriated papules are disposed symmetrically on the extensor surfaces of the limbs, the upper back, and sometimes on the face and the scalp.

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Subacute prurigo

page: 245

continued

basic lesion

cause

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Subacute prurigo

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11.7

Lupus erythematosus

page: 246

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Lupus erythematosus

basic lesion

The eruption consists of erythematous patches covered with an adherent hyperkeratotic layer, predominantly at the hair follicles. It resolves into cicatricial atrophy.

cause

1. Face

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Discoid lupus erythematosus

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Lupus erythematosus

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1. Face

basic lesion

The erythema is associated with severe oedema, producing one or more swollen patches with distinct margins, a smooth surface, and an oedematous consistency. A rare form is lupus erythematosus tumidus.

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continued

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Discoid lupus erythematosus

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Lupus erythematosus

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alphabetical

Other skin diseases

2. Scalp

basic lesion

This consists of erythematous and somewhat atrophic alopecic plaques which heal with scarring.

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continued

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Discoid lupus erythematosus

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Lupus erythematosus

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cause basic lesion

The eruption corresponds to a profuse form consisting of erythematous and somewhat scaly polycyclic annular plaques which resolve to leave depigmentation and telangiectasia.

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Subacute lupus erythematosus

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Lupus erythematosus

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Other skin diseases

basic lesion

The eruption is in the form of slightly oedematous erythematous sheets, without atrophy or follicular hyperkeratosis. The lesions are often symmetrical and located on areas exposed to the sun ("butterfly" appearance).

cause

1. Face

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Systemic lupus erythematosus

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Other skin diseases

2. Fingers

basic lesion

The site of the lesions on the fingers is usually around the nails. The lesions are usually erythematous and telangiectatic, sometimes violet (chilblain-like in appearance).

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continued

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Systemic lupus erythematosus

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11.8

Jessner and Kanof disease

page: 252

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Jessner and Kanof disease

basic lesion

cause

picture

The eruption consists of more or less tumid smooth erythematous papules with a flat surface and no scaling. These lesions tend to be located on the face, neck, and the upper trunk.

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Dermatomyositis

page: 253

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Dermatomyositis

basic lesion

cause

Diffuse oedematous and telangiectatic erythema of the face. The lesions are usually found predominantly on the eyelids.

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1. Face

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Dermatomyositis

page: 254

Dermatomyositis

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continued

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2. Hands and fingers

basic lesion

cause

Lesions or purplish erythema predominantly on the dorsal surface of the hand and finger joints, mainly in the supraarticular regions.

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Scleroderma

page: 255

alphabetical

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11.10 Scleroderma

basic lesion

The condition consists of one or more indurated nacreous white plaques which have a sheen in oblique light. They are bordered by a mauve band (lilac ring) which disappears as the lesions develop.

cause

1. Plaque lesions

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Localized morphoea

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Scleroderma

page: 256

Localized morphoea

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continued

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2. Bands

basic lesion

cause

This variant of morphoea is characterized by a paramedian band of sclerosis and atrophy. In some cases actual facial hemiatrophy develops.

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Scleroderma

page: 257

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cause basic lesion

Systemic sclerosis is found mainly on the face and on the extremities. The facial expression seems fixed. The tapering of the nose and narrowing of the mouth, surrounded by radial furrows, aggravate the lack of expression.

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Systemic sclerosis

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Systemic sclerosis

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Scleroderma

continued

basic lesion

cause

The sclerodactyly is characterized by tapering of the fingers, which become fixed in flexion. There are painful ulcerations on the pulps.

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Lichen sclerosus

page: 259

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Other skin diseases

11.11 Lichen sclerosus

basic lesion

cause

Well-circumscribed shiny white papules resembling mother-ofpearl, with a slight depression at the centre, sometimes clustered in plaques with fragmented margins.

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Skin (glabrous skin)

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continued

Vulva

basic lesion

The vulval mucosa assumes a nacreous white shiny appearance. There are sometimes areas of bruising.

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Lichen sclerosus

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Other skin diseases

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Lichen sclerosus

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Lichen sclerosus

continued

Glans penis

basic lesion

cause

Porcelain-white patches which are either disseminated or, more often, located around the meatus.

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Sarcoidosis

page: 262

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Other skin diseases

11.12 Sarcoidosis

cause basic lesion

Small, round, well-circumscribed elevations, either isolated or multiple, measuring 1 to 3 mm in diameter. Their colour is red, violet, or sepia. They appear yellowish on vitropression.

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Papular form

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continued

Nodular form

basic lesion

Larger lesions (diameter 5 to 10 mm). These are smooth, firm, violet or brownish red, and have the same appearance of yellowish lupoid infiltration on vitropression.

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Sarcoidosis

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Other skin diseases

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page: 264

continued

Angiolupoid form

basic lesion

This very rare clinical variant consists of a tumid, round or oval, reddish violet infiltration appearing on the nose.

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Sarcoidosis

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Sarcoidosis

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page: 265

continued

Scar sarcoidosis

basic lesion

Development of sarcoid nodules around foreign matter contained in a scar. These nodules sometimes appear in the context of active systemic sarcoidosis. Sometimes, however, they represent a simple local granulomatous reaction.

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Sarcoidosis

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11.13 Granuloma annulare

basic lesion

Small, firm, well-circumscribed nodules with a smooth surface, which are normal or pink in colour and show little inflammation. They are clustered in rings which spread outwards from the centre. The ring does not generally exceed a diameter of 1 to 2 cm. Giant annular granulomas (several centimetres in diameter) are much more rare.

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Granuloma annulare

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Necrobiosis lipoidica

11.14 Necrobiosis lipoidica

basic lesion

cause

Large sclerotic and atrophic pretibial plaque with distinct margins, red and telangiectatic. Its surface is shiny, which explains the "hot spot" on the photograph.

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Necrobiosis lipoidica

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Necrobiosis lipoidica

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basic lesion

cause

The centre of the plaque is smooth, with a cicatricial appearance which is often yellowish owing to an excess of fat.

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11.15 Vasculitis

basic lesion

The term vasculitis is used collectively for diseases associated with inflammation of the walls of blood vessels in the skin and other organs. The classification of vasculitis is usually based on two features: the calibre of the affected vessels and the type of inflammatory reaction. Urticarial vasculitis is included in the section on urticaria.

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Vasculitis

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Cutaneous vasculitis (allergic vasculitis)

basic lesion

Histologically, cutaneous vasculitis is characterized by infiltration of polymorphonuclear neutrophils, which are often pyknotic, into and around the vessel walls, hence the often-used term leucocytoclastic vasculitis. It occurs in two main welldefined forms: purpuric and necrotic.

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Vasculitis

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Cutaneous vasculitis (allergic vasculitis)

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Purpuric form

basic lesion

In this form the lesions essentially correspond to infiltrated purpuric papules, which affect mainly the legs and which can extend over other skin areas.

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Vasculitis

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Cutaneous vasculitis (allergic vasculitis)

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Necrotic form

basic lesion

Purpuric papules coexist with vesiculobullous, pustular, or necrotic lesions, hence the old name used in the French literature: "Gougerot's triad".

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Atrophie blanche (livedo vasculitis)

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Picture of chronic vasculitis of the ankle regions, characterized by purpura which necroses rapidly, leaving very small painful ulcerations bordered by a violet ring.

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Vasculitis

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basic lesion

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Atrophie blanche (livedo vasculitis)

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Vasculitis

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Vasculitis

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cause basic lesion

The clinical appearance is generally polymorphic, combining cutaneous nodules, livedo, infiltrated purpura, and necrotic ulcerations. These cutaneous signs are part of general systemic illness (weight loss, fever, aching all over the body).

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Polyarteritis nodosa

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Vasculitis

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cause basic lesion

Very rare vasculitis characterized by the appearance of red or violet papules, plaques, and nodules distributed symmetrically over the extensor surfaces of the limbs. The course is chronic and successive episodes are accompanied by fever.

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Erythema elevatum diutinum

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Erythema nodosum

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11.16 Erythema nodosum

basic lesion

cause

Painful red nodules found mainly on the extensor surfaces of the legs, usually accompanied by fever and pains in the joints.

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The eruption

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Erythema nodosum

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Erythema nodosum

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Regression

basic lesion

cause

The nodules resolve in about ten days and turn blue and yellow, like bruises.

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Nodular vasculitis (panniculitis)

11.17 Nodular vasculitis (panniculitis)

basic lesion

cause

Firm cyanotic nodules with little inflammation, located on the lower third of the legs. They occur in women, usually overweight women suffering from chronic venous insufficiency.

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11.18 Pyoderma gangrenosum Superficial ulceration with circular margins, bordered by a firm inflammatory swelling, which is undermined by deep-seated purulent lesions. The condition can be idiopathic or associated with various internal diseases, in particular, diseases of the digestive tract such as Crohn's disease or ulcerative colitis. The illustrations correspond to two stages of development of the same lesion in a leg.

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Pyoderma gangrenosum

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Pyoderma gangrenosum

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Pyoderma gangrenosum

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11.19 Erythema multiforme Erythema multiforme is a syndrome of the skin and mucosa associated with various aetiological circumstances, among which herpes infections occupy an important place. Non-bullous "target" form Dull red, round, symmetrical maculopapules on the backs of the hands. The characteristic configuration is like a target or butterfly.

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Erythema multiforme

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Erythema multiforme

page: 283

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Erythema multiforme

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Non-bullous "target" form

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Erythema multiforme

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Bullous form

basic lesion

The maculopapules in a butterfly configuration are bullous in the centre and can follow a necrotic course. The mucous membranes are sometimes affected.

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Erythema multiforme

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Erythema multiforme

continued

Stevens-Johnson syndrome

basic lesion

This is the most severe form of erythema multiforme. In addition to the cutaneous symptoms there are severe erosive mucosal lesions affecting the lips, buccal cavity, and sometimes the genital organs. The clinical picture is severe, with fever and alterations of the general condition.

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Erythema multiforme

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Sweet's syndrome (acute febrile neutrophilic dermatosis)

11.20 Sweet's syndrome (acute febrile neutrophilic dermatosis)

basic lesion

cause

Well-circumscribed infiltrated erythematous plaques, depressed at the centre, appearing on the limbs. Raised temperature, aching joints, abdominal pain, and neutrophilia accompany the skin symptoms.

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Bullous pemphigoid

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11.21 Bullous pemphigoid

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Early stage

basic lesion

cause

Large urticaria-like polycyclic patches, bordered by a few firm bullae of varying size and containing a clear liquid.

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Bullous pemphigoid

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Bullous pemphigoid

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Further development

basic lesion

cause

Presence of very numerous firm bullae of varying size, some of which are haemorrhagic. Some bullae rupture, leaving extensive skin erosions.

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11.22 Autoimmune forms of pemphigus Two forms of autoimmune pemphigus are distinguished, according to the preferred site of separation of epidermal cells from each other: "deep" pemphigus (pemphigus vulgaris and pemphigus vegetans) on the one hand and "superficial" pemphigus (pemphigus erythematosus) on the other.

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Autoimmune forms of pemphigus

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Pemphigus vulgaris basic lesion

Skin Presence of superficial flaccid bullae, which rupture easily to expose extensive erosions.

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Pemphigus vulgaris

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Oral

basic lesion

Dragging painful erosions of the buccal mucosa of the inside of the cheeks, the palate, and the dental cuffs, exposing a bright red surface without a fibrinous coating. Similar erosions can occur in other bullous diseases, but in pemphigus they are more constant and more characteristic.

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Autoimmune forms of pemphigus

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Autoimmune forms of pemphigus

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cause basic lesion

Crusty, scaly, erythematous plaques of the seborrhoeic regions on the face and the trunk, which are sometimes itchy. These lesions represent the development of superficial bullae.

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Pemphigus erythematosus

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basic lesion

cause

This variant is also characteristic of drug-induced pemphigus (d-penicillamine).

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Pemphigus erythematosus

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11.23 Benign familial chronic pemphigus (Hailey-Hailey disease)

basic lesion

Erosive vesiculobullous lesions which become covered with small yellowish crusts. The lesions are clustered in well-defined plaques traversed by very characteristic parallel fissures. The preferred sites of these lesions are the sides of the neck, the axillae, and the inguinogenital region.

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Benign familial chronic pemphigus (Hailey-Hailey disease)

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11.24 Dermatitis herpetiformis

basic lesion

Urticaria -like erythematous or papular lesions surmounted by vesicles and bullae, clustered in a herpetiform ring. The symmetry of the lesions, the constant pruritus, and the association with a glutensensitive enteric disease are the other peculiarities of this rare skin disease.

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Dermatitis herpetiformis

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Dermatitis herpetiformis

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Dermatitis herpetiformis

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11.25 Linear IgA bullous disease

basic lesion

Large firm bullae containing a clear liquid, occurring on normal or erythematous skin. The usual sites are the lower part of the trunk, buttocks, perineum, and the thighs. This chronic bullous skin disease of children and adults is characterized by linear deposits of IgA in direct immunofluorescence.

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Linear IgA bullous disease

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11.26 Epidermolysis bullosa Simple epidermolysis bullosa (non-dystrophic)

basic lesion

Clear bullae of various sizes, triggered by trauma and by persistent friction, which heal without leaving a trace. The usual sites are the hands, feet, elbows, and knees in the adult and the bottom in the infant.

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Epidermolysis bullosa

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Simple epidermolysis bullosa (non-dystrophic) continued

basic lesion

There is no abnormality of the teeth or the nails. The condition is transmitted in the autosomal dominant mode.

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Epidermolysis bullosa

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Dystrophic forms of epidermolysis bullosa

basic lesion

In dystrophic forms of epidermolysis bullosa, of which there are a number of variants, the traumatic bullae leave atrophic scars and milia when they heal. Some joints can be fixed in flexion.

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Epidermolysis bullosa

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continued

basic lesion

Certain abnormalities of the teeth or the nails are sometimes associated. The mode of transmission varies according to the form of the disease.

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Epidermolysis bullosa

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11.27 Diabetic bullae

basic lesion

Translucent bullae of various sizes, haemorrhagic in rare cases, without inflammatory areola, which are usually multiple, found especially on the extremities, particularly on the feet. The condition tends to occur in complicated cases of diabetes of all types.

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Diabetic bullae

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11.28 Porphyria cutanea tarda

basic lesion

The preferred sites of porphyria cutanea tarda lesions are areas exposed to light, such as the backs of the hands and the face. On the backs of the hands the condition is characterized by several symptoms associated with increased skin fragility: serous or haemorrhagic bullae, erosions after various traumas, milia.

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Porphyria cutanea tarda

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Porphyria cutanea tarda

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basic lesion

On the face the condition is characterized mainly by hypertrichosis of the malar regions and a diffuse brownish pigmentation.

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Porphyria cutanea tarda

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Bullous phytophotodermatitis (Meadow dermatitis)

basic lesion

Erythematous vesicular or bullous eruption reproducing the pattern of a grass or leaf. Sun, humidity, and contact with the plant are the three prerequisites for the appearance of the skin condition.

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Porphyria cutanea tarda

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Acne and rosacea

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11.29 Acne and rosacea

cause basic lesion

Acne vulgaris (adolescent acne) essentially includes three types of lesion: comedones, papules and pustules. To these can be added nodules and cysts.

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Acne vulgaris

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Acne and rosacea

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Acne vulgaris

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Papulopustular acne

basic lesion

cause

Papulopustular acne essentially comprises isolated or confluent papules and very inflamed papulopustules. It is often associated with seborrhoea. Comedones are never absent.

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Acne vulgaris

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Comedo acne

basic lesion

Comedo acne is characterized by a distinct preponderance of comedones over the lesions of adolescent acne. The comedones are either open (blackheads) or closed (whiteheads). Blackheads are the prominent lesions in this illustration. Cosmetic acne often takes the form of this variant.

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Acne and rosacea

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Nodular and cystic acne In addition to the basic lesions just mentioned (comedones, papules and pustules), this form of acne presents epidermal cysts of follicular origin and inflamed nodules resulting from the rupture of these cysts. The nodules can develop into abscesses, which leave indurated, pitted, or retractile scars when they dry out.

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Acne vulgaris

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Acne and rosacea

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Acne and rosacea

page: 309

alphabetical

Other skin diseases

cause basic lesion

The lesions are polymorphic and numerous: multiple comedones, follicular cysts, pustules, nodules, and abscesses developing to form fistulae, haemorrhagic ulcers, then pitted scars and adhesions bridging the scars.

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Acne conglobata

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Acne conglobata

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Acne and rosacea

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basic lesion

cause

This form of acne classically affects the face and trunk, but it can also spread to the arms and the buttocks.

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Infantile acne (acne infantum) This variant of acne, of indeterminate origin, appears in infants aged between 3 and 6 months. It is usually severe, but in most cases fades in 1 to 2 years. It is characterized by the presence of comedones, papules, and pustules, found mainly on the cheeks. It should be distinguished from a much more rare variety of acne: neonatal acne (acne neonatorum).

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Acne and rosacea

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Acne and rosacea

page: 312

alphabetical

Other skin diseases

basic lesion

The blotchy form comprises erythema and telangiectasia affecting the nose, cheeks and sometimes the forehead and chin. Flushes appear in various circumstances: in the presence of stress or a change in ambient temperature, after the consumption of alcohol, hot drinks, or hot food.

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Blotchy form

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Rosacea

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Rosacea

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Papulopustular form

basic lesion

Inflamed papules and aseptic pustules appear on a background of telangiectatic erythema, but never comedones (which necessarily leads to rejection of the term "acne rosacea").

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Acne and rosacea

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Acne and rosacea

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cause basic lesion

This is characterized by the appearance of micropapules and micropustules on a base of erythema and oedema, mainly around the mouth, separated from the lips by a border of healthy skin. The lesions can sometimes spread to the nasolabial folds.

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Perioral dermatitis

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Drug-induced eruptions

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11.30 Drug-induced eruptions

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Well-circumscribed pigmented erythematous patch occurring 48 h after the ingestion of a drug, in this case phenacetin. The lesion resolves into a residual pigmentation which disappears gradually. Reintroduction of the drug causes a recurrence, invariably at the same site. In some cases the centre of the lesion can be bullous (fixed bullous toxic dermatitis).

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Fixed pigmented erythema

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page: 316

Maculopapular exanthema (morbilliform eruption)

basic lesion

Eruption characterized by dull red congestive patches on the skin. These vary in size and run together into sheets. Two prominent characteristics are the usual symmetry of the lesions and their itchiness. The present case is an ampicillin rash.

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Drug-induced eruptions

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Lyell's syndrome (toxic epidermal necrolysis) Detachment of large pieces of epidermis, leaving extensive areas of erosion. The eruption usually spreads all over the skin. All mucous membranes are involved in the necrolytic process. The situation is similar to that of major burns. The drug responsible in this particular case was sulfonamide.

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Drug-induced eruptions

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Drug-induced eruptions

page: 318

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Other skin diseases

cause basic lesion

Drug-induced lichenoid eruption caused by methyldopa. The clinical picture is quite similar to that of lichen planus, but the lesions are often more red and scaly.

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Lichenoid eruptions

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Lichenoid eruptions

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cause

The distribution of the lesions is symmetrical and more diffuse than in most forms of lichen planus.

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Drug-induced phototoxic eruption

basic lesion

Drug-induced phototoxic eruption associated with the ingestion of a tetracycline. Erythematous oedematous lesions whose pattern corresponds strictly to the skin areas exposed to sunlight. The borders of the lesions are as if "cut with a knife".

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Drug-induced eruptions

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Drug-induced photoallergic eruption Drug-induced photoallergic reaction associated with the ingestion of a phenothiazine. The symptoms comprise erythema, confluent papules, and plaques of weeping vesicular eczema. The lesions, which are accompanied by severe itching, spread beyond the areas exposed to the sun, in contrast to the phototoxic reactions.

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cause

Drug-induced eruptions

basic lesion

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Drug-induced eruptions

page: 322

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cause basic lesion

This drug-induced eruption is associated in the present case with intramuscular injections of vitamin B12. It is clinically monomorphic, i.e. it is characterized by the presence of papules and pustules and by the absence of comedones.

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Acneiform facial eruption

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cause basic lesion

Psoriatiform eruption associated with the ingestion of a ß-blocker. In certain cases this is an aggravation of existing psoriasis. The lesions are not usually very scaly. They can be itchy. There is an increasingly large number of suspected groups of drugs.

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Psoriatiform eruption

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cause basic lesion

Induced lupus usually assumes the appearance of subacute or systemic lupus. It is reversible when the treatment is stopped and recurs if the treatment is reintroduced. In this case the suspected drug is an anticonvulsant.

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Drug-induced lupus

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Purpuric Macule; Atrophy; Scars

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cause basic lesion

Prolonged systemic use of corticosteroids leads to a reduction in collagen tissue, culminating in atrophy of the skin. This occurs particularly on the extensor surfaces of the forearms. The atrophy is accompanied by purpura, ecchymoses, and also by these three unusual star-shaped false scars resulting from an internal tear in the dermal tissue (without a wound).

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Cortisone atrophy

page: 326

alphabetical

Drug-induced eruptions

Bromide and iodide eruptions (Halide eruptions)

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Very rare reactions to the use of drugs containing bromide or iodine. Bromide and iodide eruptions appear as plaques and lumps with infiltration and vegetation, which are sometimes covered in pustules and crusts. The illustration is of a bromide eruption caused by bromazepam.

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Drug-induced eruptions

page: 327

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Other skin diseases

cause basic lesion

Gingival hyperplasias are often provoked by a drug. The drugs most frequently blamed are anticonvulsants (phenytoin, sodium valproate) and cyclosporin, as in the present case.

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Gingival hyperplasia

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Drug-induced eruptions

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Pigmented Macules

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A specifically female skin disease, melasma is hyperpigmentation appearing on the upper part of the face (temples and forehead), but sparing the hairline. It is generally bilateral, but never perfectly symmetrical. Its colour varies from light to dark brown. Melasma occurs in pregnancy or during treatment with hormonal contraceptives. It becomes more pronounced in summer and the aggravating influence of exposure to solar ultraviolet is evident.

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Melasma (chloasma)

11.31 Skin disorders caused by physical agents Benign summer photodermatitis Small acuminate erythematous papules, a few millimetres in diameter, and papulovesicles clustered on the extensor surface of the arms (as in the present case), legs, and exposed areas of the neck and the chest. The eruption usually spares the face. It occurs a few hours after sunbathing.

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Dermal Papules

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page: 329

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Skin disorders caused by physical agents

basic lesion

Other skin diseases

Skin disorders caused by physical agents

page: 330

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Other skin diseases

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Erythematous Macule; Dermal Papules

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Small erythematous papules or oedematous plaques appearing on exposed parts of the body, especially the face (forehead, nose, cheekbones), behind the ears, the exposed area of neck and chest, and the extensor surfaces of the limbs. In more than 70% of the cases the eruption appears in spring. The patient does not have to be unaccustomed to the sun. The condition appears in the course of everyday life, whether the sky is clear or cloudy.

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Polymorphic light eruption

Skin disorders caused by physical agents

page: 331

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Other skin diseases

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Erythematous Macule

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Erythematous and cyanotic infiltrations of the toes which may become covered with clear or haemorrhagic bullae, ulcerations, or small crusts. Chilblains are purple and painful in the cold, but become red and itchy when the sufferer enters a heated room. Chilblains are most common in young women, but they are seen at all ages in both sexes. Other sites include the heels, ankles, knees, ears, etc.

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Chilblains

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page: 332

Chapter 12:

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cause

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Topographical dermatology

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12.1

Alopecia

page: 333

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Topographical dermatology

Alopecia

cause basic lesion

Alopecia areata of the scalp is characterized by the appearance of round or oval, smooth, shiny patches of alopecia which gradually increase in size. The patches are usually homogeneously glabrous and are bordered by a peripheral scatter of short brokenoff hairs known as exclamationmark hairs.

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Alopecia areata

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Alopecia areata

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page: 334

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basic lesion

Alopecia areata of the occipital region, known as ophiasis, is more resistant to regrowth. Other hair regions can also be affected: eyebrows, eyelashes, beard, and the axillary and pubic regions. In some cases the alopecia can be generalized: this is known as alopecia totalis (scalp) and alopecia universalis (whole body).

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Alopecia

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Topographical dermatology

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Alopecia

page: 335

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Pseudopelade consists of circumscribed alopecia which varies in shape and in size, with more or less distinct limits. The skin is atrophic and adheres to the underlying tissue layers. This unusual cicatricial clinical appearance can be symptomatic of various other conditions: lupus erythematosus, lichen planus, folliculitis decalvans. Some cases are idiopathic and these are known as pseudopelade.

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Pseudopelade

Alopecia

page: 336

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cause basic lesion

Plucking of the hair on a large scale. In trichotillomania the alopecia has irregular, "geographic" margins which may be distinct or indefinite. The area of alopecia can be entirely glabrous or dotted with clumps of broken hairs of very different lengths, and either smooth or covered irregularly with small excoriations or crusts caused by scratching. Similar lesions can appear on the nails (onychotillomania).

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Trichotillomania

Alopecia

page: 337

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This alopecia, known generally as baldness, occurs in adulthood both in men, where it affects the temporal regions (photo) and/or the crown, and in women, where it is confined to the central area of the scalp, in a longitudinal band which extends from the forehead to the crown. In females alopecia always leaves a large number of healthy hairs which are scattered irregularly over the alopecic area.

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Androgenetic alopecia

alphabetical

page: 338

Mucosal diseases Aphtae, aphthosis, Behçet's disease

basic lesion

Small "punched-out" ulcerations of the buccal mucosa, characterized by a yellowish base resembling the colour of fresh butter and by an erythematous inflammatory halo. Often very painful, aphthae are accompanied by lymphadenopathy.

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12.2

Mucosal diseases

cause

Topographical dermatology

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Ulcers

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page: 339

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Mucosal diseases

Aphtae, aphthosis, Behçet's disease continued

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cause

Aphthae can occur on the genital mucosa (bipolar aphthosis).

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Topographical dermatology

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page: 340

Aphtae, aphthosis, Behçet's disease continued

basic lesion

Behçet's disease is a severe condition with the additional characteristics of aphthae on the skin and an isomorphic reaction to injections.

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Mucosal diseases

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Pustules

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Mucosal diseases

page: 341

alphabetical

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cause basic lesion

Black hairy tongue comprises hypertrophy of the villi on the upper surface of the tongue. These are loaded with oxidized keratin, which explains the brown or black colour of the lesion. It can occur after the use of certain drugs, such as antibiotics or metronidazole, for example.

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Black hairy tongue

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Vegetations

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Mucosal diseases

page: 342

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Topographical dermatology

cause basic lesion

The upper surface of the tongue is criss-crossed by deep grooves running in various directions. The lingual papillae are often hypertrophic and inflamed. On discovery of this anatomical peculiarity the subjects often complain of a painful sensation (glossodynia).

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Scrotal / fissured tongue

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Geographic tongue (benign migratory glossitis) Well-defined patches denuded of papillae, surrounded by an unobtrusive whitish border. The spread of these areas is eccentric and their appearance changes from one day to the next. This could be a variant of lingual psoriasis. Association with scrotal tongue is common.

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Ulcers

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page: 343

cause

Mucosal diseases

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Topographical dermatology

12.3

Cheilitis

page: 344

alphabetical

Topographical dermatology

Cheilitis

cause basic lesion

Allergic contact dermatitis connected with the application of a lipstick containing balsam of Peru. The eczematous condition extends far beyond the limits of the vermilion zone of the lips, to spread out over the surrounding skin.

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Allergic contact cheilitis

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Erythematous Macule; Scales

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page: 345

Cheilitis caused by systemic use of isotretinoin

basic lesion

Cheilitis caused by ingestion of isotretinoin. This is a fissured, scaly, erythematous cheilitis which is dependent on the isotretinoin dose administered. There are sometimes associated episodes of epistaxis.

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Cheilitis

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Topographical dermatology

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12.4

Miscellaneous

page: 346

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Topographical dermatology

Miscellaneous

cause basic lesion

Hereditary skin disease with a characteristic topography (sides of the face, trunk). Multiple small greyish-brown papules are observed, keratotic, dry, and very adherent. These papules can run together to form extensive brownish plaques. The lesions have a very distinct tendency to increase during the months of sunshine.

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Darier's disease

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Epidermal Papules; Keratoses

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Miscellaneous

page: 347

continued

basic lesion

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Darier's disease

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Miscellaneous

page: 348

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Scales

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Condition transmitted by a dominant gene, sometimes associated with atopic dermatitis. The whole of the skin is affected, sprinkled with small dry scales, which vary in number. Improvement during the months of sunshine is typical. Acquired ichthyosis must always make one think of a paraneoplastic syndrome (e.g. underlying Hodgkin's disease).

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Ichthyosis vulgaris

alphabetical

page: 349

Sex-linked (recessive) ichthyosis

basic lesion

Also called ichthyosis nigricans, this variant of ichthyosis is found only in boys, does not spare the major skin folds, and presents in the form of wide, adherent, blackish scales.

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Miscellaneous

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Scales

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page: 350

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Sex-linked (recessive) ichthyosis

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Scales

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alphabetical

page: 351

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Hereditary palmoplantar keratoderma (Thost-Unna syndrome) Appearing very early in life (between the 4th and 8th week), this palmoplantar keratoderma represents the model of a disease with autosomal dominant transmission. There are extensive yellowish keratotic plaques, accompanied by large cracks in flexural creases of the palms. This keratoderma is distinctly demarcated and does not extend to the wrist. The keratotic lesions are accentuated by an inflammatory border. There is sometimes associated hyperhidrosis.

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Miscellaneous

page: 352

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Association of diffuse orangeyellow palmoplantar keratoderma with a scoring of small fissures and horny follicular papules producing a grid on the skin. On palpation it feels abrasive (like emery paper). The pinkish papules are pointed at the top and surmounted by a small horny follicular plug. The course is usually chronic. Episodes of erythroderma may be seen as time goes on.

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Pityriasis rubra pilaris

Miscellaneous

page: 353

alphabetical

Topographical dermatology

continued

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Pityriasis rubra pilaris

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Miscellaneous

page: 354

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Topographical dermatology

cause basic lesion

Extremely common skin disease surrounded by a fine erythematous border, characterized by slight hyperkeratosis of the hair follicle orifices. This "condition" is transmitted by an autosomal dominant gene and is usually seen on the cheeks and the temples.

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Keratosis pilaris

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Keratoses

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Keratosis pilaris

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page: 355

continued

basic lesion

In adults the exterior surfaces of the arms and anterior surfaces of the thigh are most frequently affected. The affected areas feel abrasive on palpation. Exposure to sunlight attenuates the condition.

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Miscellaneous

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Topographical dermatology

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Keratoses

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Erythema annulare centrifugum (Darier's)

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Erythematous Macule

Extensive annular lesions of the arms with the appearance of healing at the centre. The distinctly infiltrated erythematous margins spread slowly outwards. Having appeared suddenly, this condition has become chronic, each ring developing over several weeks at a rate of 2 to 3 mm per week. It should be noted that when two rings join together they never overlap. There is no pruritus. It is always important to check for a possible underlying cause, though in a number of cases erythema annulare centrifugum remains idiopathic.

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alphabetical

page: 356

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Miscellaneous

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Topographical dermatology

Erythema annulare centrifugum (Darier's)

continued

Among the potential causes the following should be remembered: remote infectious foci, viral diseases, Hodgkin's disease, visceral cancer, autoimmune thyroiditis, lupus erythematosus, liver disease, etc. In the present case it was viral hepatitis B which, after an acute episode, subsequently developed into chronic active hepatitis.

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alphabetical

page: 357

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Miscellaneous

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Topographical dermatology

12.5

Leg ulcers

page: 358

alphabetical

Topographical dermatology

Leg ulcers

cause basic lesion

Extensive ulceration with pliant borders and outlines which vary from one case to the next. The base of the ulcer is granular in some places and sanious and necrotic in others. Surrounding trophic disorders are evident: gravitational purpura, atrophie blanche.

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Venous leg ulcer

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Ulcers; Atrophy

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Venous leg ulcer

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page: 359

continued

basic lesion

This type of ulcer can be the result of a varicose disorder or a postphlebitic syndrome. It represents more than 80% of leg ulcer cases. It affects women most frequently and there is an evident hereditary factor. The pains vary individually in intensity and are improved by lying down.

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Leg ulcers

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Topographical dermatology

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Ulcers

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Leg ulcers

page: 360

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Crusts; Ulcers

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cause basic lesion

Punched-out ulceration which is most often unilateral. Its site is near the ankle. There is no associated trophic disorder. The pulse in the foot can be felt only with difficulty. Ischaemic ulcers develop rapidly and cause intense pain which is often aggravated by lying down. They are much less common than venous ulcers and can be found in diabetes, arteriosclerosis, or Buerger's disease.

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Ischaemic (arterial) leg ulcer

Leg ulcers

page: 361

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Slow and relatively superficial ulceration with jagged and irregular margins. There is surrounding pigmentary and purpuric angiodermatitis, sometimes associated with small patches of atrophie blanche. The pains are often intense and persistent, and are not influenced by lying down. Diabetes and arteriosclerosis promote this condition.

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Ulcer caused by capillaritis

Neurotrophic leg ulcer (perforating ulcer) Deep circular, punched-out ulcer found at the bearing surface of the metatarsal joint. The base is necrotic. There is no tendency towards spontaneous cicatrization. There is virtually no pain. In the present case it is caused by diabetes with a major neuropathological component. Other neurological conditions can be responsible (e.g. syringomyelia).

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alphabetical

page: 362

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Leg ulcers

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Topographical dermatology

page: 363

alphabetical

Leg ulcers

continued

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cause

Neurotrophic leg ulcer (perforating ulcer)

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Pathomimicry Skin self-mutilation simulated disease Extensive escharotic ulceration of the back of the hand, caused intentionally with caustic soda. The margins are distinct, the angular edges and the configuration "surprising". The appearance of the lesion was very rapid and recurrences at the same site are typical.

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page: 364

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12.6

Pathomimicry

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Topographical dermatology

Skin self-mutilation simulated disease

alphabetical

page: 365

continued

basic lesion

The course is usually capricious, spontaneous healing retarded, and persistence indefinite. In the present case the patient acted voluntarily with intent to deceive, for her own advantage (extension of sick leave from work).

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Pathomimicry

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Self-mutilation, pathomimicry Ulceration of exogenous origin on the face, with distinct margins and "aberrant" configuration. This particular topography is rarely found in cases of disease simulation. True pathomimicry is caused by the patient who is "unconscious" of it or shows "dual consciousness".

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page: 366

cause

Pathomimicry

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Topographical dermatology

page: 367

Self-mutilation, pathomimicry

alphabetical

Pathomimicry

continued

basic lesion

cause

Major psychological disturbances are present. There is no evident intention to take financial advantage of the condition.

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Topographical dermatology

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Crusts; Ulcers

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alphabetical

page: 368

Chapter 13:

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Benign skin tumours

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13.1

Epidermal tumours

page: 369

alphabetical

Benign skin tumours

Epidermal tumours

cause basic lesion

Excrescences of varying size, covered with a greasy, scaly keratotic layer which is not very adherent. They can have various colours: yellow, sepia, grey, dark brown, or pure black. Each lesion seems to be "placed" on the skin surface, is well-circumscribed, has no underlying infiltration.

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Seborrhoeic keratosis / wart

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Epidermal tumours

page: 370

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Benign skin tumours

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continued

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Seborrhoeic keratosis / wart

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Epidermal tumours

page: 371

alphabetical

Benign skin tumours

cause basic lesion

The epidermal naevus appears in the form of raised papuloverrucous lesions, rough to the touch and sometimes fragmented. It is usually disposed in continuous linear bands following the Blaschko's classical lines, to be interrupted over the midline.

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Verrucous epidermal naevus

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Epidermal tumours

page: 372

alphabetical

Benign skin tumours

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basic lesion

cause

The colour is that of normal skin, sometimes greyish or brownish.

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Verrucous epidermal naevus

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Warts; Keratoses

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page: 373

Inflammatory linear verrucous epidermal naevus (ILVEN)

basic lesion

ILVEN appears in the form of psoriatiform scaly erythematous patches, which are sometimes lichenoid or verrucous, disposed in linear bands following Blaschko's lines (like the lesions of verrucous epidermal naevus).

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Epidermal tumours

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Benign skin tumours

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Erythematous Macule; Warts; Pustules; Scales; Gangrene None specific last screen viewed

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page: 374

Inflammatory linear verrucous epidermal naevus (ILVEN) continued

basic lesion

Inflammatory episodes can occur, causing exacerbation of pruritus, more or less severe excoriations, secondary eczematization, and even areas of necrosis.

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Epidermal tumours

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Benign skin tumours

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Becker's naevus (pigmented and hairy epidermal naevus) Hyperpigmented unilateral plaque, the preferred site of which is the chest or the shoulder, sometimes covered in hairs. It appears most often in young adults after exposure to the sun. It corresponds to a late epithelial (epidermal and follicular) naevus with secondary epidermal melanin hyperpigmentation.

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Pigmented Macules

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page: 375

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Epidermal tumours

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Benign skin tumours

Epidermal tumours

page: 376

alphabetical

Benign skin tumours

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Clear cell acanthoma

basic lesion

cause

Small, round and domed firm tumour, which is generally isolated, pink in colour, usually with a moist surface. The diagnosis of this lesion is essentially histopathological.

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Epidermal tumours

page: 377

alphabetical

Benign skin tumours

cause basic lesion

Very well defined nodule surmounted by a central horny plug. Its growth is rapid, the maximum size of the lesion being reached in a few weeks. The lesion usually regresses spontaneously in a few months.

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Kerato-acanthoma

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Spectacle frame acanthoma (fissured acanthoma)

basic lesion

Well-circumscribed, slightly pink retro-auricular papulonodule, 1-2 cm in diameter, surrounded by an inflammatory halo. The lesion is divided in two by a groove (fold).

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Epidermal tumours

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Benign skin tumours

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Epidermal tumours

Spectacle frame acanthoma (fissured acanthoma) continued

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cause

Acanthoma occurs in the weeks or months after the patient starts wearing a new spectacle frame.

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Benign skin tumours

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13.2

Follicular and sebaceous tumours

page: 380

alphabetical

Benign skin tumours

Follicular and sebaceous tumours

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Nodules

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cause basic lesion

Inflammatory subcutaneous nodule, often with a punctiform opening at its centre, through which malodorous whitish or yellowish material can be expressed. It is a single or multiple lesion which occurs especially in seborrhoeic areas, within the context of acne vulgaris or nodulocystic acne. Epidermoid cysts are sometimes wrongly called "sebaceous cysts".

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Epidermoid cyst

Follicular and sebaceous tumours

page: 381

alphabetical

Benign skin tumours

cause basic lesion

Generally located on the scalp, it appears in the form of a subcutaneous nodule covered with non-adherent pink and glabrous skin. The cysts are sometimes multiple. They range from pea-size to egg-size and are colloquially known as wens.

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Trichilemmal cyst (pilar cyst)

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Follicular and sebaceous tumours

page: 382

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Benign skin tumours

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Dermal Papules

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cause basic lesion

Milia are very superficial small white elevations which occur in various circumstances. In newborn babies they appear as innumerable small white dots on the face, as illustrated in the photograph, caused by transient retention of sebum. They disappear spontaneously in a few weeks. In adolescents and adults they are commonly seen on the cheeks, the eyelids, and the nose, and are due to clogging of follicles.

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Milia

Follicular and sebaceous tumours

page: 383

alphabetical

Benign skin tumours

cause basic lesion

Translucent, flattened or globular papular formations, 2 to 5 mm in diameter, pink or white in colour and sometimes surmounted by fine telangiectasias. Their preferred site is the face (nose, nasolabial folds, cheeks, forehead, chin). These are generally multiple and hereditary lesions, appearing from childhood or in adolescence.

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Trichoepithelioma

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Follicular and sebaceous tumours

page: 384

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Benign skin tumours

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cause

These adenomas correspond to senile adenomatous hyperplasia of the sebaceous glands.

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Senile sebaceous adenoma

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Follicular and sebaceous tumours

page: 385

alphabetical

Benign skin tumours

continued

basic lesion

Small yellowish umbilicate formations, 3 to 6 mm in diameter, occurring on seborrhoeic areas of the face (forehead, temples, cheeks) in both sexes after the age of fifty.

cause

continued

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Senile sebaceous adenoma

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Follicular and sebaceous tumours

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cause basic lesion

This is a tumour on the scalp or the face, which is often congenital. Its appearance changes with age. During childhood there is an oval or pink and slightly raised alopecic plaque. Starting from puberty the surface becomes mamillated and warty, and assumes the characteristic orange-yellow colour. In adulthood it can, in exceptional cases, give rise to a basal-cell carcinoma.

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Jadassohn's sebaceous naevus

13.3

Sweat gland tumours

page: 387

alphabetical

Benign skin tumours

Sweat gland tumours

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Syringoma

basic lesion

cause

Small, always multiple lesions measuring 1 to 3 mm in diameter and forming smooth, fleshcoloured papules generally occurring on the face (especially the eyelids), chest, neck, and axillae.

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Benign skin tumours

cause basic lesion

Solitary benign congestive tumour bleeding in pinpoint haemorrhages, the wide base of which is encircled by a keratin collar. Its preferred site is the area of the sole around the heel.

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Eccrine poroma

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Eccrine poroma

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Sweat gland tumours

continued

basic lesion

cause

In differential diagnostics it must be distinguished from pyogenic granuloma and achromic malignant melanoma.

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Benign skin tumours

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Sweat gland tumours

page: 390

alphabetical

Benign skin tumours

cause basic lesion

Multiple benign tumours, often familiar, appearing on the scalp, which becomes mamillated and embossed (turban-like tumours). The surface of these tumours is smooth, glabrous, normal or pink in colour, with telangiectasias. There is no adherence to deep layers.

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Cylindroma

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13.4

Connective tissue tumours

page: 391

alphabetical

Benign skin tumours

Connective tissue tumours

cause basic lesion

Nodular intradermal tumour 5 to 6 mm in diameter, firm to the touch, generally located on the legs. Its surface is pigmented to varying degree and often slightly keratotic. A dermatofibroma can sometimes be caused by an insect bite.

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Dermatofibroma

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Dermatofibroma

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page: 392

continued

basic lesion

An unusual variant is the pastillelike fibroma, a pink shiny nodule with a smooth surface surrounded by a very fine scaly collarette separated from the tumour by a groove.

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Connective tissue tumours

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Benign skin tumours

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Connective tissue tumours

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Benign skin tumours

cause basic lesion

Small tumour situated on the fingers or toes, more rarely on the palms and soles. Like the pastille fibroma, it is a solitary domed lesion, sometimes elongated and pedunculate, surrounded by a fine demarcating border. The surface is slightly warty. It is perhaps caused by a trauma.

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Acquired digital fibrokeratoma

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Warts

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Connective tissue tumours

page: 394

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Benign skin tumours

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Scars

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cause basic lesion

Red and taut fibrous tumour with a smooth surface, slightly dented and sometimes surrounded by pseudopodia-like extensions called crab legs. They are very often itchy, painful, or tender. Post-traumatic keloids secondary to wounds, burns, vaccinations, or inflammatory skin lesions (such as adolescent acne) are distinguished from spontaneous keloids, which are more common in black people.

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Keloid

alphabetical

page: 395

Skin tag (acrochordon, molluscum pendulum)

basic lesion

Small and very soft fleshy mass, on average 3 to 5 mm in diameter, implanted in the skin by a thin stalk. These lesions are often multiple and their preferred sites are the axillae or inguinal flexures, the neck, the eyelids, and the orbital area.

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Connective tissue tumours

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Benign skin tumours

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Connective tissue tumours

page: 396

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Benign skin tumours

cause basic lesion

Single or multiple papulonodular yellow, orange or brown lesion of soft consistency, usually appearing on the face, scalp, trunk, and the base of the limbs. It occurs most frequently in neonates and infants, but can also be seen in children and even in adults.

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Juvenile xanthogranuloma

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Connective tissue tumours

page: 397

alphabetical

Benign skin tumours

cause basic lesion

Small hemispherical papules, from a few millimetres to a centimetre in diameter, pink or orange in colour, sometimes very yellow on vitropression. The preferred sites are the elbows, knees, and buttocks.

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Tuberous xanthoma

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page: 398

Tuberous xanthoma

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Connective tissue tumours

continued

basic lesion

cause

A rare variant (eruptive xanthoma) is found in cases of severe hypertriglyceridaemia.

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Benign skin tumours

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Benign skin tumours

basic lesion

cause

Flattened and clearly delimited yellowish or orange plaques around the eyes. This is one of the variants of xanthoma planum.

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Xanthelasma palpebrarum

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Benign skin tumours

cause basic lesion

Single or multiple benign tumours the colour of normal skin, which develop from subcutaneous fat. They are soft in consistency and they can attain a large size.

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Lipoma

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Benign skin tumours

cause basic lesion

Benign tumours originating from the smooth muscles connected with hair follicles, genitals, nipples, or blood vessels. Leiomyomas are single or multiple, contractile, nodular tumours, which are red, pink, or brownish in colour.

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Leiomyoma

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Connective tissue tumours

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Benign skin tumours

This is the most common form, encountered in all age groups. It produces a fairly monomorphic eruption of smooth violet or brown itchy macules or maculopapules. The reactivity of the lesions to certain stimuli, such as rubbing, is very characteristic (Darier's sign). Basic Lesions:

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Urticaria pigmentosa

basic lesion

The term mastocytosis covers all lesions caused by the proliferation of mast cells in skin.

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Cutaneous mastocytosis

Connective tissue tumours

page: 403

alphabetical

Benign skin tumours

continued

Mastocytoma

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Cutaneous mastocytosis

basic lesion

cause

Single firm tumour, orange in colour, occurring only in children.

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Connective tissue tumours

page: 404

alphabetical

Benign skin tumours

basic lesion

Nodules which are of normal skin colour or pink. Their firmness can vary. Their essential characteristic is that they are readily depressible.

cause

Neurofibroma

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Neural crest diseases

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Neural crest diseases

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page: 405

continued

Von Recklinghausen neurofibromatosis

basic lesion

This is the most common form of systemic neural crest disease. It is essentially characterized by the combination of café au lait spots, “freckling", and cutaneous neurofibromas.

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Connective tissue tumours

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Benign skin tumours

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Neural crest diseases

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page: 406

continued

Von Recklinghausen neurofibromatosis

basic lesion

The "principal tumour" is a neurofibroma which is very large in relation to all those surrounding it. This hereditary condition is transmitted by an autosomal dominant gene with high penetrance and variable expression.

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Connective tissue tumours

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Benign skin tumours

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Connective tissue tumours

page: 407

Neural crest diseases

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Benign skin tumours

continued

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Bourneville's tuberous sclerosis (epiloia)

cause

Tuberous sclerosis is a condition with autosomal dominant transmission, characterized by various isolated or associated clinical signs and symptoms.

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Nodules

basic lesion

a. Angiofibroma Small, firm, pink or red tumid nodules covered in fine telangiectases and distributed symmetrically over the face: nasolabial folds, cheeks, perioral region.

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Neural crest diseases

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Benign skin tumours

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b. Periungual fibromas (Koënen's tumours)

basic lesion

cause

Very rare horny angiofibromas of the toes.

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Neural crest diseases

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Connective tissue tumours

continued

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c. Shagreen patch

cause

Raised patch with an irregular outline and surface, covered with pale "orange-skin". Its preferred site is the lumbosacral region. d. Achromic patches Fairly regular macules 1 to 10 cm in diameter, oval, rounded, or more characteristically in the shape of an ash leaf. They are white and do not have a hyperaemic or pigmented halo.

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Benign skin tumours

Connective tissue tumours

page: 410

alphabetical

Benign skin tumours

Angioma picture

Spider telangiectasis

basic lesion

cause

Vascular star, composed of a red central point, sometimes raised and pulsatile, and arborizations radiating outwards. The arborizations disappear on vitropression.

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page: 411

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Hereditary haemorrhagic telangiectasia (Osler-Rendu-Weber disease) Autosomal dominant disease, characterized by telangiectases of the skin and mucous membranes, often not appearing until after puberty. The telangiectatic macules are poorly defined and the arborizations, in contrast to spider telangiectasis, are not symmetrical. They occur predominantly on the face, hands, buccal mucosa, the lips, and the tongue. Basic Lesions:

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Connective tissue tumours

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Benign skin tumours

Angioma

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page: 412

continued

Angioma planum

basic lesion

Congenital erythematous macule of varying intensity, extent, and shape. The colour varies from pale pink to dark red. Its preferred site is the face and the limbs, but it can spread to the mucosa. From the fourth decade of life the angioma thickens and superficial violet nodules can appear.

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Connective tissue tumours

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Benign skin tumours

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Angioma

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page: 413

continued

Tuberous angioma

basic lesion

Bright red, distinctly demarcated, raised angioma in infants, projecting above the surrounding normal skin. Its growth is rapid, and it can bleed and ulcerate. Most of these angiomas disappear spontaneously in childhood, leaving no trace.

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Connective tissue tumours

cause

Benign skin tumours

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Vascular Macule; Nodules

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Angioma

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page: 414

continued

Subcutaneous angioma

basic lesion

Tumour protruding under skin which is either normal, bluish, or telangiectatic. This lesion does not undergo spontaneous involution.

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Connective tissue tumours

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Benign skin tumours

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Angioma

alphabetical

page: 415

continued

Angiokeratoma

basic lesion

Papular telangiectasia with a hyperkeratotic surface. Angiokeratomas of the scrotum and vulva are the most common. They are usually benign. Nevertheless, if they have disseminated over the buttocks, one must investigate for Fabry's disease.

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Connective tissue tumours

cause

Benign skin tumours

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Dermal Papules; Keratoses

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Angioma

alphabetical

page: 416

continued

Glomus tumour

basic lesion

Small, bluish intradermal tumour, remarkable for its painfulness. Its site is most likely to be peripheral, on the hands and feet, more rarely on the forearms and buttocks. A common and characteristic site is the subungual region.

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Connective tissue tumours

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Benign skin tumours

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Connective tissue tumours

page: 417

Angioma

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Benign skin tumours

continued

basic lesion

cause

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Glomus tumour

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Connective tissue tumours

page: 418

Angioma

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Benign skin tumours

continued

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Pyogenic granuloma

basic lesion

cause

Fleshy vascular pimple secondary to minimal or unnoticed trauma. Its eroded surface bleeds easily. Pyogenic granuloma may be "nipped" at its base by a characteristic groove which separates it from neighbouring skin.

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Angioma

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page: 419

continued

Senile angioma (cherry angioma)

B

Small bright red patches, flat or slightly tumid. Extremely common in old people, usually multiple and found on the trunk (A). In many cases they coexist with seborrhoeic warts (keratoses) (B).

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Connective tissue tumours

cause

Benign skin tumours

basic lesion

A

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Connective tissue tumours

page: 420

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Benign skin tumours

B

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Vesicles

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cause basic lesion

A

Pseudovesicular elevations 1 to 5 mm in diameter, arranged in clusters or irregular plaques, translucent and taut but readily depressible. The lesions can occur anywhere on the body, but are more commonly found on the trunk and the base of the limbs. Lymphangioma (A) is very often found concomitantly with hemangionma (B).

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Lymphangioma

alphabetical

page: 421

Chondrodermatitis nodularis helicis (painful nodule in the ear)

basic lesion

Inflammatory nodule of the helix, which is painful or tender. Its centre is keratotic or crater-like. It is nowadays regarded as a chondrodermatitis, but its aetiology has not been clarified.

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Connective tissue tumours

cause

Benign skin tumours

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Connective tissue tumours

page: 422

alphabetical

Benign skin tumours

cause basic lesion

Small, firm, flesh-coloured translucent nodule, occurring on the backs of the fingers near the distal interphalangeal joints and often causing a characteristic nail deformation with longitudinal grooves. It is the result of the accumulation of a mucoid substance in the dermis.

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Mucoid pseudocyst

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13.5

Melanocytic naevi

page: 423

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Benign skin tumours

Melanocytic naevi

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cause basic lesion

Small (1 to 3 mm) brown or black hyperpigmented macules which can be distributed all over the skin and/or mucous membranes. Lentigines are often isolated. Sometimes they are generalized (lentiginosis) and form part of complex syndromes involving several internal organs. They represent epidermal hypermelanocytosis.

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Lentigo

Melanocytic naevi

page: 424

alphabetical

Benign skin tumours

cause basic lesion

Bluish grey macules varying in size from a few millimetres to tens of centimetres and occurring most frequently on the loins and buttocks. They are especially common in Orientals. These spots represent dermal hypermelanocytosis.

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Mongolian spot

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page: 425

Melanocytic naevi (naevocytic naevi)

basic lesion

Melanocytic naevi are wellcircumscribed lesions which show a wide variety of colour, shape, thickness, consistency, and size, their diameter ranging from a few millimetres to a few centimetres.

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Melanocytic naevi

cause

Benign skin tumours

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Melanocytic naevi (naevocytic naevi)

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page: 426

continued

basic lesion

They can be flat or raised, lenticular or discoid, and vary in colour from pale yellow to black-brown. The domed forms may be without pigmentation.

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Melanocytic naevi

cause

Benign skin tumours

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Melanocytic naevi

page: 427

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Benign skin tumours

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Hairy melanocytic naevus

basic lesion

cause

Some melanocytic naevi become covered in hairs at puberty.

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Melanocytic naevi

page: 428

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Benign skin tumours

cause basic lesion

Congenital pigmented naevi vary in size. Some are called giant because of their wide spread. They have an inhomogeneous surface (flat, papular, nodular, verrucous) and are most often variegated in colour, which ranges from light brown to black. They are often covered with thick hairs.

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Congenital pigmented naevus

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Melanocytic naevi

page: 429

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Benign skin tumours

cause basic lesion

Isolated pinkish papulonodular tumour, frequently located on the face or the limbs. The histopathological appearance of this melanocytic naevus is very characteristic. In fairly exceptional cases there may be multiple Spitz naevi.

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Spitz naevus (juvenile)

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Melanocytic naevi

page: 430

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Benign skin tumours

cause basic lesion

Small nodule, often less than a centimetre in diameter, blue-grey to black-blue in colour and situated especially frequently on the back of the hands and the feet, sometimes on the face. Its colour is caused by the deep dermal site of the melanocytic clusters.

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Blue naevus

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Melanocytic naevi

page: 431

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Benign skin tumours

cause basic lesion

Sutton's naevus is a melanocytic naevus surrounded by a depigmented corona. In the course of its natural development the naevus component gradually disappears and the white halo undergoes gradual repigmentation. This feature of its course is probably autoimmune.

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Halo naevus (Sutton's naevus)

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Benign skin tumours

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cause

continued

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Halo naevus (Sutton's naevus)

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Melanocytic naevi

page: 433

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Benign skin tumours

cause basic lesion

Presence of a more or less dark brown longitudinal band in the nail plate (melanonychia), clinical evidence of the existence of a melanocytic naevus in the matrix region.

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Naevus of the nails

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page: 434

Chapter 14:

basic lesion

cause

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Premalignant skin tumours

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Solar keratoses (senile keratoses)

basic lesion

Raised red and well-defined plaques with a rough surface covered in scales of varying thickness. The lesions are isolated or multiple and their preferred site is on exposed regions such as the back of the hands or the face.

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alphabetical

page: 435

cause

Premalignant skin tumours

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Keratoses; Scales

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The lesions are isolated or multiple and their preferred site is on exposed regions such as the back of the hands or the face. Here one can observe some characteristics of skin-ageing caused by sunlight: sallow skin, accentuated wrinkles, etc. If left untreated, some cases of solar keratosis develop into squamous cell carcinoma.

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cause

Solar keratoses (senile keratoses)

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page: 436

basic lesion

Premalignant skin tumours

page: 437

alphabetical

Premalignant skin tumours

cause basic lesion

Relatively well-demarcated scaly erythematous plaque, sometimes encrusted and occurring essentially on the lower lip. Under the hyperkeratotic layer the epithelium is atrophic and bleeds easily at the slightest trauma. Actinic cheilitis spreads slowly over time and can degenerate into true squamous cell carcinoma.

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Actinic cheilitis

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Erythematous Macule; Scales; Crusts

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Leucoplakia – smoker's keratosis (stomatitis nicotina)

basic lesion

Well-demarcated and more or less rounded white or greyish plaques on the lower lip or the buccal mucosa. They occur more frequently in men and are probably promoted by smoking. Their natural evolution is in the direction of squamous cell carcinoma.

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alphabetical

page: 438

cause

Premalignant skin tumours

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Achromic macules; Warts

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Premalignant skin tumours

cause basic lesion

Slightly raised round or oval discoid lesion with distinct borders, varying in size, red or reddish brown in colour and covered with a crust of scales or with small crusts. The current understanding of Bowen's disease is that it is an intraepidermal carcinoma (in situ).

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Bowen's disease

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continued

basic lesion

cause

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Bowen's disease

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Premalignant skin tumours

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Premalignant skin tumours

cause basic lesion

Mucosal site of Bowen's disease. Red, well-demarcated, slightly protuberant plaque, with a glazed surface, on the glans penis. Similar lesions are observed on the vulval mucosa.

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Eryhtroplasia of Queyrat

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Premalignant skin tumours

cause basic lesion

Erythematous or brownish papules on the glans and shaft of the penis, the vulva, and sometimes the perianal region. Their histopathology is similar to that of Bowen's disease. Human papillomaviruses (16, 18, 33) are the initial cause of this papulosis.

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Bowenoid papulosis

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Epidermal Papules

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Premalignant skin tumours

cause basic lesion

Cicatricial atrophy, telangiectases, and pigmentation abnormalities form the classical picture of radiodermatitis. At a further stage ulcerations can appear. Basal cell carcinoma or squamous cell carcinoma are liable to develop after several years.

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Radiodermatitis

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Ulcers; Atrophy; Scars

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Premalignant skin tumours

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cause basic lesion

A hereditary disease with recessive autosomal transmission. The genetic basis of xeroderma pigmentosum is an enzyme deficiency resulting in disorders of DNA repair after ultraviolet irradiation. The condition is characterized by extreme photosensitivity and chronic actinic lesions including skin atrophy, freckles, and solar keratosis. Some tumours can develop early: keratoacanthoma, basal cell or squamous cell carcinoma, malignant melanoma.

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Xeroderma pigmentosum

page: 445

alphabetical

Premalignant skin tumours

Dubreuilh's melanosis

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Pigmented Macules

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basic lesion

Polychromatic pigmented macule, not raised and poorly defined. Its colour varies from pale beige to black. Dubreuilh's melanosis is observed in old people, most frequently on the face, less so on the back of the hands and on the legs. It spreads very slowly, reaching a diameter of several centimetres in about ten years.

cause

picture

(Lentigo maligna melanoma, melanosis circumscripta precancerosa of Dubreuilh)

alphabetical

page: 446

Chapter 15:

basic lesion

cause

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Malignant skin tumours

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15.1

Basal cell carcinomas

page: 447

alphabetical

Malignant skin tumours

Basal cell carcinomas

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Nodules

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cause basic lesion

Globular tumour with a waxy or reddish tint, more or less translucent ("pearly" carcinoma), the smooth surface of which is streaked with fine telangiectases. The most common site is the face, but other areas can also be involved: back, limbs, genital region. Nodular basal cell carcinoma increases gradually in size and can ulcerate.

picture

Nodular basal cell carcinoma

Basal cell carcinomas

page: 448

alphabetical

Malignant skin tumours

This variant of ulcerated basal cell carcinoma is characterized by

picture

Rodent ulcer

2. considerable superficial spread 3. considerable spread in depth: the tumour "eats" into the tissue (hence "rodent ulcer") 4. the persistence of a translucent pearly and slightly telangiectatic border is very characteristic of basal cell carcinoma. Basic Lesions:

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Nodules; Ulcers

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cause

1. an ulcer as the primary lesion

Flat cicatricial basal cell carcinoma ("scleroderma-like" carcinoma) This variant of carcinoma appears more like a plaque than a nodule. The whole central area of the lesion is white, atrophic, sclerous, and morphoea-like, but unlike morphoea it is streaked with telangiectases. At the edge of the lesion there is usually a pearly, telangiectatic, indurated swelling, sometimes covered with small crusts.

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Nodules; Atrophy; Sclerosis

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alphabetical

page: 449

cause

Basal cell carcinomas

basic lesion

Malignant skin tumours

Basal cell carcinomas

page: 450

alphabetical

Malignant skin tumours

picture

Pigmented basal cell carcinoma

basic lesion

cause

A very rare variant, pigmented basal cell carcinoma is characterized by a considerable excess of melanin. It is usually nodular and is not ulcerated.

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Nodules

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Pagetoid basal cellular carcinoma (superficial basal cell carcinoma) The usual appearance is a pink plaque distinctly circumscribed by rounded outlines. Its limits are usually marked by a fine, pearly, filiform edge, which distinguishes it from Bowen's disease. Growth is very slow. The preferred site of this variant is on the trunk.

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Erythematous Macule; Scales

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alphabetical

page: 451

cause

Basal cell carcinomas

basic lesion

Malignant skin tumours

alphabetical

page: 452

Squamous cell carcinomas

basic lesion

The majority of squamous cell carcinomas are seen on uncovered areas: face (lower lip in particular) and the back of the hands. They develop either in apparently healthy skin, or, most frequently, over a precancerous lesion: solar keratosis, Bowen's disease, etc. They are liable to metastasize, mainly via lymph.

picture

15.2

Squamous cell carcinomas

cause

Malignant skin tumours

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Nodules

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page: 453

Squamous cell carcinoma of the face

basic lesion

Large, ulcerated, which oozes blood and forms crusts. The peripheral swelling is very indurated. The base of the whole lesion is distinctly infiltrated.

picture

Squamous cell carcinomas

cause

Malignant skin tumours

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page: 454

Squamous cell carcinoma of the lower lip

basic lesion

This sanious ulceration is surrounded by an indurated peripheral swelling. In the present case it is developing from actinic cheilitis.

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Squamous cell carcinomas

cause

Malignant skin tumours

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Nodules; Scales; Crusts; Ulcers

Causes:

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page: 455

alphabetical

Squamous cell carcinomas

Squamous cell carcinoma of the penis

basic lesion

cause

Hard ulcerated vegetating tumour of the glans.

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Malignant skin tumours

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Paget's disease Encrusted scaly erythematous and locally erosive plaque on the nipple and the areola. Its perfectly defined border distinguishes it from an eczematous reaction (see page 52). The disappearance of the nipple's elevation must also be noted. This carcinoma is seen in 3 to 5% of breast cancers and develops mainly in postmenopausal women. Extramammary sites are rare and confined to skin areas with apocrine sweat glands (genitals, perineum, perianal region).

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alphabetical

page: 456

cause

15.3

Paget's disease

basic lesion

Malignant skin tumours

page: 457

alphabetical

15.4

Cutaneous metastases

Cutaneous metastases Cutaneous metastases of deep cancers can assume various clinical appearances: Carcinomatous lymphangitis

basic lesion

cause

Classically observed in cancer of the breast, characterized by an extensive inflammatory plaque, sometimes wrongly called "carcinomatous erysipelas".

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Malignant skin tumours

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Cutaneous metastases

alphabetical

Cutaneous metastases

continued

Nodularcutaneous-subcutaneous metastases

basic lesion

cause

forming skin-embedded spherical colourless or bluish masses.

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Malignant skin tumours

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page: 459

Melanoma (malignant)

basic lesion

Melanoma is a tumour which develops either as a primary lesion from epidermal melanocytes or from the cells of congenital junctional and compound naevi, or much more rarely from intradermal and blue naevi. It metastasizes via lymph and/or blood. Several variants of melanoma have been described:

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15.5

Melanoma (malignant)

cause

Malignant skin tumours

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Pigmented Macules; Nodules

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Superficial spreading melanoma (SSM) Slightly raises melanotic spot, varying in colour from brown to black, with a margin. It undergoes a horizontal growth phase lasting several months and then finally starts its vertical phase, in which it invades the deep tissue. It occurs anywhere on the body, but more readily on the back in men and on the legs in women.

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page: 460

cause

Melanoma (malignant)

basic lesion

Malignant skin tumours

Melanoma (malignant)

page: 461

alphabetical

Malignant skin tumours

cause basic lesion

Infiltrated brown or black nodules, sometimes violet-red and more rarely achromic. The lesion, which is often dome-shaped, finally ulcerates and bleeds.

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Nodular melanoma

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Melanoma (malignant)

page: 462

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Malignant skin tumours

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Melanoma developing over Dubreuilh's melanosis precancerosa

basic lesion

cause

Infiltrated nodular formations, which may or may not be pigmented, sometimes oozing blood, developing from a Dubreuilh's melanosis.

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Pigmented Macules; Nodules

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Acral lentiginous melanoma (melanoma of the extremities) Located on the extremities (palm of the hands, sole of foot, digital extremities), it resembles superficial spreading melanoma or nodular melanoma, representing only a particular site of either of these. The illustration suggests this double categorization particularly well.

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Pigmented Macules; Nodules

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alphabetical

page: 463

cause

Melanoma (malignant)

basic lesion

Malignant skin tumours

Melanoma (malignant)

page: 464

alphabetical

Malignant skin tumours

basic lesion

cause

Numerous black or bluish indurated nodules developing near a previously excised melanoma.

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Melanoma metastases

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Large multinodular dented tumour which adheres to the skin surface without ulcerating it and infiltrates the dermis and subcutaneous tissue, often beyond the limits of palpation. The tumour develops gradually, without painful symptoms. It affects adults of both sexes with a preference for the trunk and the base of the limbs. This fibrosarcoma has local malignancy, but can metastasize in exceptional cases.

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Dermatofibrosarcoma protuberans (Darier-Ferrand fibrosarcoma)

cause

15.6

Dermatofibrosarcoma protuberans (Darier-Ferrand fibrosarcoma)page:

basic lesion

Malignant skin tumours

15.7

Kaposi's angiosarcoma

page: 466

alphabetical

Malignant skin tumours

Kaposi's angiosarcoma

basic lesion

cause

picture

Violet nodules on the ankles and feet in an elderly patient. In the present case it is not occurring in the context of acquired immune deficiency syndrome.

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Vascular Macule; Nodules

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page: 467

Malignant lymphomas – mycosis fungoides

basic lesion

Among the many malignant cutaneous lymphomas, mycosis fungoides (epidermotropic Tlymphoma) represents an unusual entity. At the eruptive stage, the clinical picture is characterized by dull coppery red infiltrated plaques distributed in arcs.

picture

15.8

Malignant lymphomas – mycosis fungoides

cause

Malignant skin tumours

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Erythematous Macule; Nodules

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page: 468

alphabetical

Malignant lymphomas – mycosis fungoides

Malignant lymphomas – mycosis fungoides continued

basic lesion

cause

Tumours can subsequently develop, and these may ulcerate.

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Malignant skin tumours

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Paraneoplastic syndromes Malignant neoplasms can be accompanied by skin diseases which themselves are not neoplastic in character, nor directly caused by the presence of the tumour (in contrast to metastases), but which develop alongside the malignant neoplasm, regressing if and when the latter is eliminated and reappearing if it recurs. These so-called paraneoplastic dermatoses can occur when the malignant neoplasm has already distinctly developed, but they can also appear as a sign revealing a small neoplasm (Bazex's sign).

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alphabetical

page: 469

cause

15.9

Paraneoplastic syndromes

basic lesion

Malignant skin tumours

Bazex's paraneoplastic acrokeratosis Paraneoplastic skin diseases are, amongst others, malignant acanthosis nigricans, Gammel's erythema gyratum repens, and Bazex's paraneoplastic keratosis, hypertrichosis lanuginosa. Both last diseases have been selected to illustrate paraneoplastic syndromes.

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Warts; Keratoses

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page: 470

cause

Paraneoplastic syndromes

basic lesion

Malignant skin tumours

Paraneoplastic syndromes

page: 471

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Malignant skin tumours

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This occurs suddenly (within a few weeks), in the form of a down of long, white, silky, fine, and extremely numerous lanuginous hairs extending all over the glabrous skin and especially on the face. The rate of growth is accelerated and the hair (of the head) becomes more luxuriant. The papillae on the lingual mucosa are hypertropic and glazed. There is a distinct change in the sense of taste.

picture

Hypertrichosis lanuginosa

Paraneoplastic syndromes

page: 472

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Malignant skin tumours

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The appearance of such a picture must lead one to suspect the presence of an associated neoplasm. In the present case a neoplasm was detected in the breast. Radical treatment of the cancer leads to the disappearance of the acquired lanuginous hypertrophy. The recurrence of the neoplasm is accompanied by reappearance of the hypertrichosis (paraneoplastic dermatosis in the strict sense).

basic lesion

continued

picture

Hypertrichosis lanuginosa

alphabetical

page: 473

Chapter 16:

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cause

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Algorithmic approach to a dermatological diagnosis

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Urticaria

Physical Urticaria?

No

Yes

Provoked by direct contact with a substance?

No

Yes

Genetic origin?

No

Yes

Systemic origin?

No

Yes

Medicamentouse or food allergy?

No

Yes

Infectious origin?

No

Yes

To conclude this pictorial presentation of the most common skin diseases for the general practitioner, we thought it would be interesting to include the modern diagnostic procedure in dermatology applied to an everyday problem: urticaria.

If duration is longer than 6 weeks: Chronic idiopathic urticaria

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page: 474

basic lesion

16.1

Urticaria

cause

Algorithmic approach to a dermatological diagnosis

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alphabetical

Urticaria

Physical urticaria

Simple or retarded dermographism

Aquagenic urticaria

Click

Vibratory angio-oedema

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Solar urticaria

Click

Cholinergic urticaria

Delayed pressure urticaria

Click

Cold urticaria

No Physical urticaria

Click

Heat urticaria

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Click

Click

Click

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basic lesion

Click

picture

Algorithmic approach to a dermatological diagnosis

page: 476

Physical urticaria Simple or retarded dermographism Rub with a blunt tip.

alphabetical

Urticaria

picture

Algorithmic approach to a dermatological diagnosis

basic lesion

Continue

cause

other disease

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Urticaria

page: 477

Physical urticaria

alphabetical

Algorithmic approach to a dermatological diagnosis

Photosensitivity test.

picture

Solar urticaria

other disease

basic lesion

cause

Continue

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Urticaria

page: 478

Physical urticaria

alphabetical

Algorithmic approach to a dermatological diagnosis

Small papules induced by heat, physical effort, stress.

picture

Cholinergic urticaria

basic lesion

Continue

cause

other disease

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Urticaria

page: 479

Physical urticaria

alphabetical

Algorithmic approach to a dermatological diagnosis

Test with ice cube sheathed in plastic.

picture

Cold urticaria

basic lesion

Continue

cause

other disease

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Urticaria

page: 480

Physical urticaria

alphabetical

Algorithmic approach to a dermatological diagnosis

Aquagenic urticaria Immersion test: hand in water at ambient temperature.

cause

Test with test-tube of hot water.

picture

Heat urticaria

Professional circumstances ( particularly pneumatic hammer). other disease

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Vibratory angio-oedema

Urticaria

page: 481

Physical urticaria

alphabetical

Algorithmic approach to a dermatological diagnosis

Test by pressure with a weight strapped on to the body.

picture

Delayed pressure urticaria

basic lesion

Continue

cause

other disease

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Urticaria

page: 482

Provoked by direct contact with a substance

alphabetical

Algorithmic approach to a dermatological diagnosis

Rapid result patch test, prick test or scratch test.

picture

Contact urticaria

basic lesion

Continue

cause

other origin

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Genetic origin Hereditary angioneurotic oedema Investigate for deficiency of C1 esterase inhibitor. other origin

basic lesion

Continue

alphabetical

page: 483

picture

Urticaria

cause

Algorithmic approach to a dermatological diagnosis

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Systemic origin Lesions persisting at the same place for more than 24h, not very itchy, accompanied by joint pains and myalgias; histopathological appearance that of vasculitis.

alphabetical

Urticaria

picture

Algorithmic approach to a dermatological diagnosis

2

-

acute lupus erythematosus (1-3) Still’s disease macroglobulinaemia blood disease hyperthhyroidism urticarial vasculitis (4)

other origin 4

3

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basic lesion

1

cause

Investigate for:

Medicamentous or food allergy Painstaking history with regard to drugs and food - Drugs Especially acetylsalicylic acid (see photos) - Food Especially preservatives and colourings

alphabetical

page: 485

picture

Urticaria

cause

Algorithmic approach to a dermatological diagnosis

other origin

Continue

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basic lesion

Do provocation tests.

- Hepatitis A (photo) Exceptional case of figured urticaria revealing hepatitis A in its initial phase. The yellowish colour of the central oedematous (urticated zone) is caused by accumulation of bilirubin in the oedema fluid. -

Hepatitis B or C Infectious mononucleosis Parasitosis Focus of bacterial infection Focus of mycotic infection other origin

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Infectious origin

picture

page: 486

cause

Urticaria

basic lesion

Algorithmic approach to a dermatological diagnosis

alphabetical

page: 487

basic lesion

cause

picture

Picture Index

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alphabetical

page: 488

Skin from the forehead region

Skin from the face of an elderly subject

Structure of the epidermis

Structure of the epidermis

Structure of the epidermis

basic lesion

Skin from the axillary region

cause

picture

Picture Index

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alphabetical

page: 489

Vascular macule

Purpuric macule

Pigmentary macules

Pigmentary macules

Pigmentary macules

basic lesion

cause

Erythematous macule

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alphabetical

page: 490

Dermal papules

Dermo-epidermal papules

Nodules

Tubercles

Vegetations

basic lesion

cause

Epidermal papules

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alphabetical

page: 491

Keratoses

Vesicles

Bullae

Pustules

Scales

basic lesion

cause

Warts

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alphabetical

page: 492

Excoriations (or ulcerations)

Fissures

Ulcers

Gangrene

Atrophy

basic lesion

cause

Crusts

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Sclerosis

Acute exudative contact dermatitis

Chronic occupational contact dermatitis

Vesicular contact dermatitis

Vesicular contact dermatitis

basic lesion

Scars

cause

picture

alphabetical

page: 493

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alphabetical

page: 494

Bullous contact dermatitis

Crusted eczema

Crusted eczema

Scaly dry erythematous contact dermatitis

Acute irritant dermatitis

basic lesion

cause

Bullous contact dermatitis

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Chronic palmar irritant dermatitis

Atopic dermatitis of the face in an infant

Infected retro-auricular dermatitis

Atopic dermatitis of childhood

Atopic dermatitis of the folds in a child

basic lesion

Cumulative insult dermatitis

cause

picture

alphabetical

page: 495

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Atopic cheilitis

Atopic dermatitis in the adult

Atopic conjunctivitis

Atopic dermatitis of the hands in the adult

Pityriasis alba

basic lesion

Eczema of the nipples

cause

picture

alphabetical

page: 496

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alphabetical

page: 497

Juvenile plantar dermatosis

Nummular dermatitis

Nummular dermatitis

Gravitational eczema

Seborrhoeic dermatitis of the trunk

basic lesion

cause

Juvenile plantar dermatosis

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alphabetical

page: 498

Seborrhoeic dermatitis of the face

Pompholyx of the fingers

Bullous pompholyx of the palms

Eczematous pompholyx of the palms

Asteatotic eczema

basic lesion

cause

Seborrhoeic dermatitis of the hairline

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Prick test with latex

Provocative use test with latex gloves

Dermographism

Pressure urticaria

Cold urticaria

basic lesion

Latex contact urticaria

cause

picture

alphabetical

page: 499

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picture

alphabetical

page: 500

Urticated weals

Papular urticaria

Figured urticaria

Hereditary angio-oedema

Urticarial vasculitis

basic lesion

cause

Solar urticaria

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alphabetical

page: 501

Herpes, type II (genital)

Varicella

Varicella

Zoster of the trunk

Ophthalmic nerve zoster

basic lesion

cause

Herpes, type I

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alphabetical

page: 502

Plane warts

Plane warts

Condylomata acuminata

Plantar wart

Mosaic warts

basic lesion

cause

Common warts

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alphabetical

page: 503

Hairy leucoplakia

Molluscum contagiosum

Multiple mollusca contagiosa

ORF

Erythema infectiosum

basic lesion

cause

Horny filiform wart

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alphabetical

page: 504

Measles

Hand-foot-and-mouth-disease

Hand-foot-and-mouth-disease

Hand-foot-and-mouth-disease

Rubella

basic lesion

cause

Erythema infectiosum

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page: 505

Necrotic herpes zoster

Seborrhoeic dermatitis

Prurigo

Gingivitis

Molluscum contagiosum

basic lesion

cause

Necrotic herpes zoster

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page: 506

Kaposi's sarcoma

Condylomata acuminata

Bullous impetigo

Non-bullous impetigo

Ecthyma

basic lesion

cause

Kaposi's sarcoma

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page: 507

Furuncle (BOIL)

Carbuncle

Erysipelas

Erysipelas

Orbital cellulitis

basic lesion

cause

Folliculitis

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page: 508

Erythema chronicum migrans

Erythema chronicum migrans

Borrelia pseudolymphoma

Proteus infection

Cat-scratch disease

basic lesion

cause

Septic emboli

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page: 509

Intertrigo

Lupus vulgaris

Lupus vulgaris

Scofuloderma

Complication of BCG vaccination

basic lesion

cause

Cat-scratch disease

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Infection with mycobacterium marinum

Infection with mycobacterium fortuitum or chelonae

Erythrasma

Trichomycosis axillaris

Pitted keratolysis

basic lesion

Infection with mycobacterium marinum

cause

picture

alphabetical

page: 510

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picture

alphabetical

page: 511

Syphilitic chancre (primary sore)

Secondary syphilis

Late secondary syphilis

Papular syphilids

Genital gonorrhoea

basic lesion

cause

Syphilitic chancre (primary sore)

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alphabetical

page: 512

Tinea corporis

Tinea faciei

Tinea faciei

Tinea cruris

Tinea manuum

basic lesion

cause

Tinea corporis

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page: 513

Tinea pedum (athlete's foot)

Tinea pedum (athlete's foot)

Tinea pedum (athlete's foot)

Tinea capitis or ringworm

Kerion

basic lesion

cause

Tinea manuum

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Kerion

Onychomycosis due to dermatophytes

Onychomycosis due to dermatophytes

Thrush

Angular cheilitis

basic lesion

Kerion

cause

picture

alphabetical

page: 514

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picture

alphabetical

page: 515

Candidal intertrigo

Candidal vulvovaginitis

Candidal balanitis

Candidal paronychia and subungual infection

Napkin candidiasis (infant)

basic lesion

cause

Candidal intertrigo

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picture

alphabetical

page: 516

Pityriasis versicolor

Pityriasis versicolor

Sporotrichosis

Mycetoma (Madura foot)

Human scabies

basic lesion

cause

Pityriasis versicolor

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picture

alphabetical

page: 517

Human scabies

Human scabies

Animal scabies

Pediculosis (head lice)

Pediculosis (head lice)

basic lesion

cause

Human scabies

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picture

alphabetical

page: 518

Crab lice (pubic lice)

Trombiculiasis

Trombiculiasis

Infantile papular urticaria (strophulus)

Flea bites

basic lesion

cause

Crab lice (pubic lice)

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picture

alphabetical

page: 519

Leishmaniasis

Leishmaniasis

Leishmaniasis

Larva migrans (creeping eruption)

Larva migrans (creeping eruption)

basic lesion

cause

Flea bites

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picture

alphabetical

page: 520

Tungiasis (chigger)

Psoriasis vulgaris

Psoriasis vulgaris

Psoriasis vulgaris

Psoriasis vulgaris

basic lesion

cause

Tungiasis (chigger)

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page: 521

Psoriasis vulgaris

Psoriasis vulgaris

Psoriasis vulgaris

Pustular psoriasis

Pustular psoriasis

basic lesion

cause

Psoriasis vulgaris

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page: 522

Psoriatic erythroderma

Psoriatic erythroderma

Palmoplantar psoriasis

Flexural psoriasis

Psoriasis of the nails

basic lesion

cause

Pustular psoriasis

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page: 523

Psoriasis of the face

Mucosal psoriasis

Mucosal psoriasis

Pityriasis rosea

Pityriasis rosea

basic lesion

cause

Psoriasis of the scalp

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page: 524

Varioloid parapsoriasis

Varioloid parapsoriasis

Chronic superficial scaly dermatitis

Premycotic

Simple cutaneous lichen planus

basic lesion

cause

Pityriasis lichenoides

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page: 525

Simple cutaneous lichen planus

Oral lichen planus

Oral lichen planus

Hypertrophic lichen planus

Hypertrophic lichen planus

basic lesion

cause

Simple cutaneous lichen planus

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page: 526

Graft versus host disease

Graft versus host disease

Lichenification

Subacute prurigo

Subacute prurigo

basic lesion

cause

Lichen planus of the nails

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page: 527

Discoid lupus erythematosus

Discoid lupus erythematosus

Subacute lupus erythematosus

Systemic lupus erythematosus

Systemic lupus erythematosus

basic lesion

cause

Discoid lupus erythematosus

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page: 528

Dermatomyositis

Dermatomyositis

Localized morphoea

Localized morphoea

Systemic sclerosis

basic lesion

cause

Jessner and Kanof disease

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page: 529

Lichen sclerosus

Lichen sclerosus

Lichen sclerosus

Sarcoidosis

Sarcoidosis

basic lesion

cause

Systemic sclerosis

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page: 530

Sarcoidosis

Granuloma annulare

Necrobiosis lipoidica

Necrobiosis lipoidica

Vasculitis

basic lesion

cause

Sarcoidosis

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Cutaneous vasculitis

Cutaneous vasculitis

Atrophie blanche

Atrophie blanche

Polyarteritis nodosa

basic lesion

cause

Cutaneous vasculitis

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page: 532

Erythema nodosum

Erythema nodosum

Nodular vasculitis

Pyoderma gangrenosum

Pyoderma gangrenosum

basic lesion

cause

Erythema elevatum diutinum

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Erythema multiforme

Erythema multiforme

Erythema multiforme

Sweet's syndrome

Bullous pemphigoid

basic lesion

cause

Erythema multiforme

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Pemphigus vulgaris

Pemphigus vulgaris

Pemphigus erythematosus

Pemphigus erythematosus

Benign familial chronic pemphigus

basic lesion

cause

Bullous pemphigoid

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Dermatitis herpetiformis

Linear IgA bullous disease

Simple epidermolysis bullosa

Simple epidermolysis bullosa

Dystrophic forms of epidermolysis bullosa

basic lesion

cause

Dermatitis herpetiformis

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Diabetic bullae

Porphyria cutanea tarda

Porphyria cutanea tarda

Bullous phytophotodermatitis

Acne vulgaris

basic lesion

cause

Dystrophic forms of epidermolysis bullosa

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Acne vulgaris

Acne vulgaris

Acne conglobata

Acne conglobata

Infantile acne

basic lesion

cause

Acne vulgaris

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page: 538

Rosacea

Perioral dermatitis

Fixed pigmented erythema

Maculoppapular exanthema

Lyell's syndrome

basic lesion

cause

Rosacea

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Lichenoid eruptions

Drug-induced phototoxic eruption

Drug-induced photoallergic eruption

Acneiform facial eruption

Psoriatiform eruption

basic lesion

Lichenoid eruptions

cause

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page: 539

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page: 540

Cortisone atrophy

Bromide and iodide eruptions

Gingival hyperplasia

Melasma

Benign summer photodermatitis

basic lesion

cause

Drug-induced lupus

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page: 541

Chilblains

Alopecia areata

Alopecia areata

Pseudopelade

Trichotillomania

basic lesion

cause

Polymorphic light eruption

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page: 542

Aphtae, aphthosis, Behçet's disease

Aphtae, aphthosis, Behçet's disease

Aphtae, aphthosis, Behçet's disease

Black hairy tongue

Scrotal / fissured tongue

basic lesion

cause

Androgenetic alopecia

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Allergic contact cheilitis

Cheilitis caused by systemic use off isotretinoin

Darier's disease

Darier's disease

Ichthyosis vulgaris

basic lesion

Geographic tongue

cause

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page: 543

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Sex-linked (recessive) ichthyosis

Hereditary palmoplantar keratoderma

Pityriasis rubra pilaris

Pityriasis rubra pilaris

Keratosis pilaris

basic lesion

Sex-linked (recessive) ichthyosis

cause

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page: 544

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page: 545

Erythema annulare centrifugum

Erythema annulare centrifugum

Venous leg ulcer

Venous leg ulcer

Ischaemic (arterial) leg ulcer

basic lesion

cause

Keratosis pilaris

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page: 546

Neurotrophic leg ulcer

Neurotrophic leg ulcer

Skin self-mutilation simulated disease

Skin self-mutilation simulated disease

Self-mutilation, pathomimicry

basic lesion

cause

Ulcer caused by capillaritis

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page: 547

Seborrhoeic keratosis / wart

Seborrhoeic keratosis / wart

Verrucous epidermal naevus

Verrucous epidermal naevus

Inflammatory linear verrucous epidermal naevus

basic lesion

cause

Self-mutilation, pathomimicry

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Becker's naevus

Clear cell acanthoma

Kerato-acanthoma

Spectacle frame acanthoma

Spectacle frame acanthoma

basic lesion

cause

Inflammatory linear verrucous epidermal naevus

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Trichilemmal cyst

Milia

Trichoepithelioma

Senile sebaceous adenoma

Senile sebaceous adenoma

basic lesion

cause

Epidermoid cyst

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Syringoma

Eccrine poroma

Eccrine poroma

Cylindroma

Dermatofibroma

basic lesion

cause

Jadassohn's sebaceous naevus

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Acquired digital fibrokeratoma

Keloid

Skin tag

Juvenile xanthogranuloma

Tuberous xanthoma

basic lesion

cause

Dermatofibroma

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Xanthelasma palpebrarum

Lipoma

Leiomyoma

Cutaneous mastocytosis

Cutaneous mastocytosis

basic lesion

cause

Tuberous xanthoma

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Neural crest diseases

Neural crest diseases

Neural crest diseases

Neural crest diseases

Neural crest diseases

basic lesion

cause

Neural crest diseases

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page: 554

Angioma

Angioma

Angioma

Angioma

Angioma

basic lesion

cause

Angioma

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page: 555

Angioma

Angioma

Angioma

Lymphangioma

Chondrodermatitis nodularis helicis

basic lesion

cause

Angioma

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page: 556

Lentigo

Mongolian spot

Melanocytic naevi

Melanocytic naevi

Hairy melanocytic naevus

basic lesion

cause

Mucoid pseudocyst

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Spitz naevus (juvenile)

Blue naevus

Halo naevus

Halo naevus

Naevus of the nails

basic lesion

cause

Congenital pigmented naevus

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Solar keratoses

Actinic cheilitis

Leucoplakia

Bowen's disease

Bowen's disease

basic lesion

cause

Solar keratoses

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Bowenoid papulosis

Radiodermatitis

Xeroderma pigmentosum

Dubreuilh's melanosis

Nodular basal cell carcinoma

basic lesion

cause

Eryhtroplasia of queyrat

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Flat cicatricial basal cell carcinoma

Pigmented basal cell carcinoma

Pagetoid basal cellular carcinoma

Squamous cell carcinomas

Squamous cell carcinoma of the face

basic lesion

cause

Rodent ulcer

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Squamous cell carcinoma of the penis

Paget's disease

Cutaneous metastases

Cutaneous metastases

Melanoma (malignant)

basic lesion

cause

Squamous cell carcinoma of the lower lip

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Nodular melanoma

Melanoma over Dubreuilh's melanosis precancerosa

Acral lentiginous melanoma

Melanoma metastases

Dermatofibrosarcoma protuberans

basic lesion

Superficial spreading melanoma

cause

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Malignant lymphomas – mycosis fungoides

Malignant lymphomas – mycosis fungoides

Paraneoplastic syndromes

Bazex's paraneoplastic acrokeratosis

Hypertrichosis lanuginosa

basic lesion

Kaposi's angiosarcoma

cause

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basic lesion

cause

Hypertrichosis lanuginosa

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