DefinitionThis section has been translated automatically.
Algorithm for comprehensive clinical detection and differential diagnosis of skin lesions. We use only 5 morphologically very easy to grasp descriptions of findings for the definition of the conduction fluorescence:
- Spots
- Sublime
- Deepening
- Hardenings
- Bearings.
- Stains: Non palpable colour changes of any kind. The stains belong together with the raised areas to the largest "efflorescence group". Their clinical differentiation is often important for diagnostic reasons. A spot is merely a colour change in the skin. With a spot, the examiner does not feel any change in the consistency of the skin.
- Elevations are divided into non-solid (prototype: blister) and solid elevations (prototype: papule):
- Blister, blister, pustule
- Papule (circumscribed skin roundness < 0,5 cm)
- Plaque (the plaque is a term for a flat raised area, e.g. psoriasis plaque)
- Nodules (circumscribed tissue consolidation lying in the skin or subcutis or protruding above the skin level > 0.5 cm)
- wheals (acute, volatile, cutaneous edema)
- Swelling (acute or chronic subcutaneous oedema with or without tissue proliferation).
- Depressions:
- scar
- Atrophy
- Erosion
- Ulcer
- Crack (Rhagade).
- Indurations (hardenings): superficial or deep, flat or knotty tissue hardening which can only be palpated.
- Deposits (scaling, crusts, fluid).
ClassificationThis section has been translated automatically.
General examination form for the classification of a dermatological disease:
- Duration of illness:
- acute: < 6 weeks
- chronic: > 6 weeks.
- Dynamic:
- chronically active: behaviour of the overall disease (noticeable growth)
- chronic stationary: constant size over months or years (not noticeable growth).
- Number of efflorescences:
- solitary = 1
- several: < 10
- multiple: > 10
- Size of the efflorescences:
- Data in cm
- Distribution of efflorescences:
- localized: limited to one body region
- generalized: distributed over several body regions
- universal: entire skin affected (e.g. erythroderma).
- Macro patterns (relationship to body silhouette):
- stretched or flexed side
- symmetrical or asymmetrical
- light
- in seborrhoic zones
- Contact points (prints)
- orthostatically emphasized
- acral accentuated
- intertriginous.
- Arrangement in certain structure fields:
- segmental
- Blaschko pattern
- Long tension lines.
- Micropatterns:
- randomly distributed (disseminated)
- grouped (herpetic; satellites)
- linear, striped
- reticular (reticulated).
- Round pattern:
- homogeneous round pattern (special feature: edge accentuation [= marginalized])
- anular round pattern (special feature: cockade pattern)
- random fusion patterns.
- Limitation of the total lesion:
- sharply defined (as drawn with a pencil)
- fuzzily limited
- toothed
- scattered (scattering phenomena)
- melting.
- Determination of the conducting fluorescence:
- Spot
- Sublimity (papule, plaque, vesicles, bladder, nodes, swelling)
- depressions (atrophy, erosion, ulcer)
- Hardening (induration).
- Height pattern of efflorescence (silhouette):
- not present
- flat engraved
- raised oval
- raised hemisphere
- conical
- ungracefully
- plumply raised with central navel.
- Consistency of efflorescence:
- normal like surrounding skin
- diminished:
- soft/spongy
- multiplied:
- slightly increased in consistency (just palpable)
- clear (like leather)
- hard (like wood)
- impact (fluctuating)
- doughy (findings in lymphedema): pitting edema (remaining impressionability) or non pitting edema (not remaining impressionability).
- Colour:
- normal skin colour
- red
- non-red
- dark colours (brown, blue, black)
- light colours (yellow, grey, white).
- Surface:
- normal like surrounding skin
- smooth
- rough.
- Bearing:
- none
- Shed
- Crusts
- Wetting
- Horn support (callus).
- Subjective symptoms (patient details):
- Itching
- Burning
- Pain.
General informationThis section has been translated automatically.
- The efflorescence group "elevations" requires further subdivision into solid and non-solid (liquid filled) elevations. Solid elevations include papules, plaque, nodules, wheals and swelling. Liquid-filled bosses include all blistered or pustular efflorescences. Bubbles and pustules are easy to diagnose even for non-dermatologists, as are solid prominences. A loftiness is "more than a spot", it is always palpable.
- The difference between papules and nodes is determined by size scale. A knot is more voluminous and larger than a papule (> 0.5 cm). It is just as easy to distinguish between papules and plaque. A plaque is not thicker than a papule, but only larger in area. Here too, the standard size is: > 0.5 cm. A plaque develops from papules that are moved together and fused to form a plateau or from a centrifugally growing papule (example: Granuloma anulare) that exceeds its defined size of 0.5 cm.
- Solid elevations:
- papule (circumscribed skin elevation; size < 0.5 cm, which only slightly exceeds the skin level)
- Nodules (circumscribed, hemispherical skin roughness; size > 0.5 cm, which usually clearly exceeds the skin level)
- Plaque (flat, plateau-like elevation of the skin; size > 0.5 cm, which only slightly exceeds the skin level or can only be detected by palpation, e.g. psoriasis plaque, sclerodermiform basal cell carcinoma)
- wheals (volatile cutaneous edema; single florescence persists < 6-12 hours; size: 0.2 cm to 20.0 cm in diameter)
- Subcutaneous swelling (angioedema).
- The distinction between papule and urtica and between plaque and urtica appears complicated. If it does not succeed at first attempt, the dynamics of efflorescence must be investigated or measured. A wheal, whether large or small, only exists as a single florescence for about 6 to a maximum of 12 hours. By marking the efflorescence, the differentiation is very precise. The marked wheal, unlike its size, will in any case disappear after 12 hours.
- The subcutaneous swelling, a pillow-like, soft skin bulge, is a clinically easy to detect phenomenon. Its dynamics play a decisive role in the etiological evaluation. Acute swellings are inflammatory, traumatic or haemodynamically induced. In chronic swellings, the etiological spectrum extends to congenital dysplasias of the blood or lymph vessel system.
- A deepening of the surface can have very different causes. It can be caused by a chronically creeping tissue atrophy (skin, subcutis or deeper lying structures) without a visible defect of the surface, by an acute or chronic trauma (traumatic tissue defect of different extent), by a neoplastic or a nutritive induced tissue loss. The morphological finding "skin ulcer" describes an open tissue defect of varying etiology.
- When assessing surfaces, a distinction can be made between:
- rough (scaly, crusty, warty)
- smooth (like the surrounding skin)
- weeping.
- Other surface parameters are:
- bumpy
- wrinkled
- horny, calloused
- hypertrichotic (increased hairiness)
- hypotrichotic
- ...with a fork.
- Some skin diseases are characterized by a centrally navelled surface structure. This phenomenon has a very practical significance in the differential diagnosis of the frequently occurring sebaceous gland hyperplasia. Senile sebaceous gland hyperplasias always show a central porus. The umbilical cord can be easily detected with the unarmed eye (or better still, by reflected light microscopy) under lateral illumination. This phenomenon is never detectable in milia or basal cell carcinomas.
- For the dermatological differential diagnosis, different skin patterns are so specific for a disease that they define a diagnosis together with the efflorescence type. A segmental blistering, acute disease is defined by the distribution pattern "segmental" e.g. the diagnosis "zoster". Two patterns can be distinguished for the distribution patterns:
- Macro-patterns (patterns in relation to the body contours): The macro-patterns include, among other things, infestation on the straight side or the flexion side, infestation of the seborrhoeic zones, the segmental distribution or infestation of the light-exposed zones.
- Micro-patterns (patterns by certain figural arrangement of the single florestones): To the micro-patterns belong anular ornamentation, linear or band ornamentation, the arrangement in the Blaschko lines, the cockade pattern and others.)
Prof. Dr. med. Peter Altmeyer