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Dermatology DDX:

Red scaly diseases

Look at a rash and decide if it is red and scaly or red and non scaly.

If it is red and scaly you use the mnemonic PMs PET


P of PM is for PITYRIASIS ROSEA or PITYRIASIS VERSICOLOR
M is for MYCOSIS FUNGOIDES, a T cell lymphoma of the skin.)
PET is PSORIASIS, ECZEMA and TINEA. )
The only additional problem there is the extent of our solar damage which can masquerade as a red scaly rash and even be non scaly.
So add solar damage after the nemonics for both the red scaly and non scaly rashes.

PITYRIASIS ROSEA (PR) is RED AND SCALY a condition that classically begins with a single, primary, 2- to 10-cm herald patch that
appears on the trunk or proximal limbs.
A general centripetal eruption of 0.5- to 2-cm rose- or fawn-colored oval papules and plaques follows within 7 to 14 days.
The lesions have a scaly, slightly raised border (collarette) and resemble ringworm (tinea corporis). Most patients itch,
occasionally severely.
Papules may dominate with little or no scaling in blacks, children, and pregnant women; the rose or fawn color is not as evident in blacks;
blacks also more commonly have inverse PR (lesions in the axillae or groin that spread centrifugally). Classically, lesions orient along skin
lines, giving PR a Christmas Tree-like distribution when multiple lesions appear on the back. A prodrome of malaise and headache precedes
the lesions in a minority of patients. Diagnosis is based on clinical appearance and distribution.

Pityriasis versicolor: RED AND SCALY This red scaly disease has fine bran like scale elicited by scratching the surface. It is usually seen
on the trunk or under the breasts.
It presents as white spot disease in tanned individuals and a red scaly disease on white skin.
Additional Diagnostic Features Often a very light pink colour and easy to miss. Look especially on the upper back, axillae and under
breasts.

The M in PMs PET is for Mycosis fungoides.

This is an old name for T cell lymphoma of the skin. It is quite rare but important to diagnose because an early lesion can look like psoriasis or low
grade eczema.
Additional Diagnostic Features :
This is a clinical diagnosis early because the initial biopsy may not be diagnostic.
Fixed or slow growing plaque,
sharp edges sometimes in bizarre shapes.
Itchy later when they thicken.

Red and scaly but with small erosions or breaks in the skin surface, sometimes oozing and often secodarily infected with Staph aureus.
Eczema is usually itchy.
The small erosions or breaks in the skin surface are the crucial diagnostic feature as is the distribution on the front of the elbow and behind
the knee.
Contact eczema remains localised at unusual areas depending on what and where you have been applying something you are allergic to.

Tinea: Red and scaly but with a spreading edge.


Scrape this for microscopy and culture.
There may be small pustules in the edge in rare cases.
Treatment with topical steroids will reduce the redness and scale making diagnosis more difficult.
Additional Diagnostic Features The SLOWLY SPREADING SCALY EDGE is a hallmark of the condition. Seldom itchy. Usually not symmetrical like psoriasis
or eczema. Fungal infections from animals are usually more inflammed.

In psoriasis Red and scaly( except for the one in the flexures, like groins etc) the skin grows 8 to 10 times faster than normal so you get this thick
build up of scale that is easily scraped off. The lesions are usually quite sharply defined, the colour is often a salmon pink colour, except
in the more inflammatory irritated types of psoriasis where it can be much redder. You should look at the more typical areas where you
would expect to see psoriasis such as theelbows, the knees, the scalp.
Look at the nails and see if there is any evidence of pitting. Look under the flexures and the elbows or breasts or in the groin area
or especially around the anus to see if there is the relatively smooth non scaly lesions that occur in these areas. Psoriasis on the lower

legs can have an eczema, tous look to it as well because of stasis features and underlying varicose veins because the patient may have
rubbed and scratched the psoriasis. This should not put you off making the diagnosis.

We have mentioned that the PMs PET is called PETAL.


The AL is to remind you of some other red scaly diseases including the Annular erythema called EAC or erythema annulare centrifugum
and the L to remind you of Lupus erythematosus and Lichen planus.
EAC will remind you of a fungal tinea infection but it has a trailing or inward looking scale rather than at the edge as in a fungus and the
lesions grow quickly and often merge together.
The L for lupus erythematosus refers to the discoid type which is usually seen on the face or back.
On the face you will mistake it for sun induced skin cancer but if you freeze it then it will just come back around the frozen area!
The scale is throughout the lesion, and is very adherent sometimes going into the hair follicles and giving a carpet tack appearance
underneath when you try to lift it off!
Other P diagnoses: There are several other rarer skin diagnoses that are red and scaly and begin with Pityriasis.
These include pityriasis rubra pilaris, pityriasis lichenoides and pityriasis alba.
A composite of these conditions is shown below and there are links to global skin atlas and dermnet for further information
Red NON
So add solar damage after the nemonics for both the red scaly and non scaly rashes
scaly diseases
The mnemonic is CUL DVA EVEI
Cellulitis,
Urticaria,
Drug reaction,
Viral exanthem or
Annular erythema.
where EVEI stands for Erythema multiforme, Vasculitis and Erythema nodosum and Infiltrates
The important thing is to establish there is no scale before using this algorithm.
Remember!!! : Some scaly disorders lose their scale if treated with topical steroids and scaly diseases such as psoriasis lose their
scale in moist flexures such as under the breasts and in the groin and axillae.

C: Cellulitis rash: red and non scaly,


Characterised by a hot, red nonscaly fixed tender area of skin which has arisen suddenly, typically on the lower legs over the shins or on

the cheeks or around a recent injury to the skin. Lymphangitis ie a red line travelling towards the local lymph glands is a worrying sign!

U
Urticaria red nonscaly Raised itchy plaques in the skin that last a few hours and disappear only to reappear elsewhere.

Individual lesions never last longer than 24 hours ecept for urticarial vasculitis where the lesions mat resolve but leave residual bruising at
the site and papular urticaria secondary to an insect bite reaction where the mechanism causing the lesion is a delayed type cell mediated
hypersensitivity reaction rather than the immediate IgE mediated histamine release from mast cells.

L Lupus, Light eruptions, Lues red nonscaly Some forms of Lupus erythematosus are not scaly eg Systemic lupus, Tumid Lupus ,
Lupus panniculitis and some cases of Subacute Lupus. These rashes are usually maximal on sun exposed areas as is Polymorphous light

eruption.
The latter occurs with unusual sun exposure particularly to people on holiday in sunny locations they are not used to. The lesions are
usually itchy sapules or plaques

D Drugs You have to consider a drug reaction for virtually every red non scaly rash. Typically sudden onset, no fever, itch prominent and the rash is florid!
Compare it with a virus infection where the onset can be just as fast and the rash just as florid but there is fever, little itch and the patient feels unwell. A drug
reaction to an antibiotic given to a patient with a viral infection is always difficult to diagnose! Look for a viral enanthem.

V Virus
Viral infections can have a variety of morphologies but macular or maculopapular are the commonest and they are red and non scaly. The
patient usually has a fever, some lymphadenopathy and feels ill. An enanthem is an associated finding often in the mouth. eg Koplick spots

on the buccal mucosae in measles.

A Annular erythemas The annular erythemas look like urticaria but individual lesions last longer than 24 hours and often slowly join
up with each other to form polycyclic rings. They can be easily misdiagnosed as a tinea fungal infection but they usually do not have a
scale except sometimes the EAC or erythema annulare centrifugum variant.

E Erythema multiforme rash: red and non scaly, This condition looks like a drug eruption which it sometimes is! Again no fever or itch

and few systemic features in the minor variant. The morphological feature you look for is the iris, bullseye or target lesion seen on the lower

legs or palms of the hands and soles of the feet. Sudden onset lasting days, occassionally blistered in severe cases due to a drug and in the very
severe cases will have involvement of the lips and conjunctival surfaces. In these circumstances it goes under the name of the Stevens-Johnson
syndrome

V Vasculitis
The early stages of true vasculitis give a red non scaly rash particularly on the lower legs or buttocks.
It does not blanch with pressure and may be purpuric or small bruise like.
Again drugs are the commonest cause but the potential range of causes is very great.
The first thing to do is check the urine and see if there is any blood in it.
If there is then you have a systemic vasculitis that can hit other organ systems including the joints, the gut , the lungs, heart and the brain.
Wide ranging investigations are necessary to diagnose the cause.

E Erythema nodosum rash: red and non scaly,This red non scaly rash is also quite distinctive presenting astender deeper nodules on the

anterior shins or sometimes on the calves. The lesions may resolve with bruising before disappearing over a 2-3 week period.
You have to consider a condition called erythema induratum when the lesions are mainly on the calves.
Erythema nodosum is a form of panniculitis or inflammation of the deeper fat tissue. Again it can be a drug reaction but most cases are
post streptococcal throat infection!

Infiltrates can present as red non scaly rashes eg Generalised granuloma annulare, sarcoidosis,
leukemic infiltrates, leprosy, leishmoniasis, mucinoses ie infiltrates of cells, substances or
infectious agents (viral, bacterial, fungal and protozoal).

So add solar damage after the nemonics for both the red scaly and non scaly rashes
Pustular diseases
If there are Pustules then the mnemonic is II
(aye aye) Infective( viral, bacterial, fungal) or Inflammatory eg psoriasis or a pustular drug reaction.
Common causes include Staph folliculitis , modified fungal infection or if the vesicles are grouped herpes simplex. Pustules
on the face are Acne, Rosacea, Staph folliculitis or H Simplex if grouped.
When we see pustules we have a tendency to think infection and often limit ourselves to only bacterial infections at that.
Remember pustules can occur with fungal and viral infections as well and never forget that some pustules are not due to
infection but to infiltration of the skin by neutrophils in Inflammatory skin diseases such as psoriasis and drug eruptions.
There are also a few other very rare inflammatory disorders such as acrodermatitis enteropathica (zinc deficiency) and the
glucagonoma syndrome from underlying pancreatic malignancy that can have pustules at the advancing edge of the lesion
and thereby simulate a fungal infection.

The images below include variants of pustular psoriasis, both localised and generalised and infected
pompholyx eczema.

Skin coloured
So add solar damage after the nemonics for both the red scaly and non scaly rashes
scaly diseases
The Skin coloured but scaly conditions are just the various forms of Ichthyosis, a group of genetic diseases of
the skin. There is a rare type of ichthyosis that is red and scaly called CIE or congenital ichthyosiform
erythroderma.

Skin Coloured non


scaly
Skin coloured non scaly lesions on the skin are usually infiltrates, ie the pathology is in the dermis rather than the epidermis.
( Involvement of the epidermis usually gives scale or crust of some sort).

Hence the lesions are skin coloured papules, possibly red if inflammed, and are not itchy. Consider sarcoidosis and granuloma annulare if
the rash is extensive and tumours such as neurofibromatosis or leiomyomas if the lesions are multiple and grouped. However one of the
commonest causes of smoothe dome shaped skin coloured papules is molluscum contagiosum, a pox virus usually seen in young children.

Annular lesions

Annular lesions are always fun to diagnose. The public invariably diagnose them as tinea or ringworm but that diagnosis is
only a possibility if there is scale. If there is no scale then the process is dermal and you should consider granuloma
annulare, sarcoidosis, annular erythema and even leprosy!
Annular lesions on the face
Tinea faciei due to a dermatophyte infection would be the commonest, but granulomatous disorders such as sarcoidosis and
granuloma annulare and infective conditions such as leprosy should also be considered.
Management - skin scrapings if scaly, check to see if there is a loss of sensation which would be seen in leprosy in the
centre of the lesion and
biopsy if you consider one
of the granulomatous
diseases.
SIGN DIP MEN
Overview of Annular
lesions
S-Squamous:
Resolving
psoriasis,
Discoid eczema,
Genital lichen
planus,
Herald patch of
Pityriasis rosea,
I-Infective
Tinea
(Ringworm),
Erythema
chronicum
migrans,
Leprosy,
Syphilis,
Erythema
marginatum,
G-Granulomatous
Granuloma
annulare,
Sarcoidosis,
Elastolytic
granuloma
N-Neoplastic
Basal cell skin cancer,
Mycosis
fungoides,
follicular
mucinosis,
Erythema gyratum repens,
Necrolytic migratory erythema,
Porokeratosis of Mibelli
D-Drugs
Reactive annular erythema after Vit K injections,
after heparin,
collagen steroid
anticancer agent injections,
I-Immunological
Urticaria,
Angioedema,
Subacute lupus erythematosus,
Neonatal lupus erythematosus,
P-Physical
Cupping,
ECG suction caps,
M-Metabolic
Reticular erythematous mucinosis
E-Endocrine
N-Nutritional
Others - Annular erythema of infancy,
Annular red brown lesions with scale and central scar:
Tertiary syphilis,
lupus vulgaris,
lupus erythematosus,
sarcoidosis,

cicatricial
pemphigoid,
leishmaniasis
(purplish scar in
recidivans)

Linear lesions

Linear lesions are also quite strikingly obvious.


Consider plant contact dermatitis, herpes zoster, lichen striatus and ILVEN or inflammatory linear
verrucous epidermal nevus! Some conditions form linear configurations after an injury or scratch.
This is known as the Koebner reaction or phenomenon and is seen most often in psoriasis.
Mosaicism of the skin can also give linear forms of innumerable skin disorders eg linear porokeratoses.
Linear lesions on the trunk include those on the chest,back and abdomen.
The commonest linear lesions on these areas would be epidermal nevi particularly ILVEN and also
lichen striatus.Inflammatory linear with blisters would suggest herpes zoster, followed by a plant
contact dermatitis or a phytophotodermatitis from a photosensitising sap or juice eg limes.
A tender thrombosed vein on the chest wall is known as Mondor's disease.

SIGN DIP MEN Overview


of Linear lesions
S-Squamous
Lichen striatus,
ILVEN(inflammatory
linear verrucous
epidermal nevus),
Psoriasis,
Lichen simplex,,
Lichen planus,
Dariers disease,
Lichen nitidus,
I-Infective
Herpes zoster,
Cutaneous larva migrans,
Warts including
molluscum
G-Granulomatous
N-Neoplastic
Porokeratoses,
Sebaceous nevus,
Epidermal nevi,
Linear benign tumours
Syringomas,
Trichoepitheliomas,

Eccrine spiradenomas,
Linear porokeratoses,,
Leiomyomas,
Segmental
neurofibromatosis,
Linear Basal cell nevus
syndrome
D-Drugs
I-Immunological
Vitiligo,
Linear Morphea,
Graft versus host
disease,
P-Physical
Scratching,
Dermatographism,
Plant contact dermatitis,
Pigmented purpuric
dermatosis,
Mondors disease,
Linear fibromatosis,
Linear common diseases
because of the Koebner
effect
M-Metabolic
Papular mucinosis
E-Endocrine
Pregnancy pigmentary lines
N-Nutritional
Others Linear lesions following Blaschkos lines,
Linear disease variants due to Mosaicism,
Incontinentia pigmenti,
Hypomelanosis of Ito,
Goltz syndrome,

Conradi syndrome

White skin
localised

Localised white skin lesions also signify a limited number of diseases.

Working down, on the face consider


pityriasis alba, a low grade form of
eczema, poliosis, a white area on the
forehead with a tuft of white hais
from birth.
If poliosis appears as a new lesion
consider localised vitiligo.
White spots on the chest or arms
with fine surface scale is pityriasis
versicolor.
White spots on the forearms or
lower legs are idiopathic guttate
melanosis, a type of inverse freckle
from sun damage.
Porcelain white spots on the
trunk with surface skin wrinkling is
due to lichen sclerosus/ morphoea.
White patches present at birth
should raise the possibility of
tuberous sclerosus.
Hypopigmentation on the trunk
includes that on the chest, back
and abdomen.
The commonest conditions causing
hypopigmentation at these sites
include 1)vitiligo, 2)Halo nevi,
3)Pityriasis versicolor and 4) post
inflammatory either after liquid
nitrogen or surgery to skin cancers.
Post inflammatory hypopigmentation
is also seen with discoid lupus
erythematosus.
5)Localised morphea or lichen
sclerosus can also present as
hypopigmented patches but the
underlying skin will be firm in
morphea.
6)Undertreated psoriasis or eczema of the trunk may also present as hypopigmented patches but some evidence of these conditions
elsewhere should allow you to make the diagnosis.
In the newborn look for the ashleaf macules of Tuberous sclerosus or pale connective tissue nevi.
Segmental vitiligo may also be seen congenitally.
Nevus depigmentosus and nevus anaemicus may also present as hypopigmented patches in this age group.

White skin
generalised

Generalised white patches on the skin usually mean vitiligo if there is no surface scale. In tropical countries also consider
tuberculoid leprosy and pinta.
SIGN DIP MEN Overview of Hypopigmentation

S-Squamous
Healing areas of eczema and psoriasis,
Pityriasis alba,
Pityriasis versicolor,
Post discoid lupus erythematosus scarring,
Tinea corporis,
I-Infective
Pityriasis versicolor,

Tuberculoid Leprosy,
Pinta, Syphilis,
Post herpes zoster
G-Granulomatous
Sarcoidosis,
N-Neoplastic
Morpheic Basal cell skin
cancer,
Epidermodysplasia
verruciformis,
D-Drugs Phenols,
I-Immunological
Vitiligo,
Halo nevi,
Localised Morphea,
Lichen sclerosus,
Scleroderma,
P-Physical
Following liquid nitrogen,
Post traumatic in dark skin,
Idiopathic
Acquired White areas
guttate
T cell lymphoma,
hypomelanosis,
Halo nevus,
Chronic
Lichen sclerosus,
radiodermatitis,
Malignant atrophic papulosis,
M-Metabolic
Pinta,
E-Endocrine
Post inflammatory,
hypopigmentation,
Segmental vitiligo,
Tinea versicolor,
N-Nutritional
V Vascular
Malignant atrophic papulosis
Hyperpigmentation
Localised

Localised congenital depigmentation Nemonic is (WANT A DIP) of


colour.
Wardenberg's,
Alezandreni,
nevus anaemicus,
nevus depigmentosus,
Tuberous sclerosus,
Dyskeratosis congenita,
Incontinentia pigmenti achromicans,

Facial hyperpigmentation if localised would be a lentigene or Hutchison's melanotic freckle,


Melasma in females or part of an epidermal or congenital nevus. Ochronosis can arise from treatment with
hydroquinone.
Localised hyperpigmentation DAMN PIG PAPA
Drugs
Fixed drug plus antimalarials,
minocycline,
cytotoxics,
bleomycin(reticulate pigmentation),
mercury and bismuth,
psoralens,
dithranol in psoriasis,
Autoimmune
Scleroderma,
lupus erythematosus,
dermatomyositis,
atrophoderma,
Metabolic
Ochronosis,
chloasma,
gaucher's disease,
kwashiorkor,
pellagra,
linea nigra,
acanthosis nigricans,
Neoplastic:
Lymphoma,
melanoma,
mastocytosis,
P

erythema dyschromicum perstans,


post inflammatory hyperpigmentation,
erythema ab igne,
lichen planus,

Infective
erythrasma,
tinea nigra
Granulomatous
leprosy,

granuloma annulare,
syphilis
P Parapsoriasis,
A Amyloid,
P Pigmented purpuric dermatosis,
A acanthosis nigricans
Hyperpigmentation in the
neonate
Blue grey
Mongolian spot,
Nevus of Ota (Face),
Nevus of Ito (Shoulder,neck),
Phakomatosis pigmentovascularis (Trunk plus port wine
stain)
Brown
Cafe au lait spots,
Congenital nevus
Small brown macules
Peutz Jeghers syndrome,
LEOPARD syndrome,
Generalised lentiginosis,
Inherited patterned
lentiginosis,
Carney syndrome,
Neurofibromatosis (axillae),
Centrofacial
lentiginosis(central face)
Segmental lentiginosis,
Mosaicism,
Speckled lentiginous nevus,
Nevus spilus,
Transient neonatal pustular
melanosis
Labial brown macules
Peutz Jeghers syndrome,
Carney syndrome
Swirled or Blaschko pattern
Linear and whorled nevoid
hyperpigmentation,
Incontinentia pigmenti,
Epidermal nevus,
Goltz syndrome,
Conradi Hunermann
syndrome,
Mosaicism
Generalised hyperpigmentation is always worrying.
It can be a feature of underlying malignancy particularly ACTH producing carcinoma of the lung or from an
underlying melanoma. Also consider Addison's disease with pigmentation of the skin creases and inside the
mouth. Drug induced hyperpigmentation is another thought particularly from some chemotherapy drugs.
Metabolic disorders such as hemochromatosis and porphyria cutanea tarda can also give marked generalised
hyperpigmentation but in PCT it is accentuated in sun exposed areas.
SIGN DIP MEN Overview of Hyperpigmentation

Hyperpigmentation
generalised

S-Squamous
Resolved lichen planus
I-Infective
G-Granulomatous
N-Neoplastic
Melanoma metastases,
Lung carcinoma,
Lymphoma
D-Drugs
Melasma,
Fixed drug eruption,
bleomycin,
arsenic,
gold and cyclophosphamide,
Puva
I-Immunological
Scleroderma,
lupus erythematosus
dermatomyositis
P-Physical
Post sunburn,
Post taumatic,

Racial pigmentary
demarcation lines,
Phototoxic
hyperpigmentation
(Plants),
Vagabonds disease
M-Metabolic
Addisons disease,
Porphyria cutanea
tarda,
Hemochromatosis,
Renal and hepatic
failure,
Amyloidosis
E-Endocrine
Hyperthyroidism,
Pregnancy,Cushings,
Acromegally,
Thyrotoxicosis,
Pheochromocytoma
N-Nutritional
Pellagra,
Malabsorption
Others
Eyelids
Familial,
nevoid,
metabolic diseases
such as ochronosis,
chemical such as
mercury ointments
and psoralens and
argyria,
lichen planus,
lichen aureus,
melanoacanthoma
and some endocrine
diseases.
Reticulate Pigmentation
Dowling
Degos(flexures),
Zosteriform,
Dyskeratosis
congenital,
Naegeli Franceschetti
syndrome (neck
axillae, keratoderma),
Acropigmentations of
Kitamura and Dohi

Blistering diseases

If there are Blisters The mnemonic is ICI(Imperial Chemical Industries) Inflammatory including Immunological,
Contact dermatitis and Infective.
Inflammatory causes can include drugs but remember Immunological causes in the elderly particularly bullous pemphigoid.
Contact dermatitis usually gives smaller vesicles rather than blisters but individual vesicles can join up into blisters. Watch for hair dye
allergies around the posterior neck and scalp or consider a plant contact dermatitis if the blisters or vesicles are in a linear streaky distribution
on exposed surfaces where the patient has brushed up against an offending bush or tree.
Infective causes of blisters are usually staph toxin in origin and go under the name of bullous impetigo. However if the lesions are in a linear
distribution but painful and limited to skin dermatomes then consider Herpes zoster or shingles.
The Bullous insect bite reaction occurs on the lower legs usually from sand fly bites and the blister is tense and intact. Blistering drug
eruptions are rare but can be seen with the antiepileptic drugs. They are usually explosive in onset and there may be mucosal involvement.
Metabolic disorders rarely give rise to skin blisters but a notable exception is seen in porphyria cutanea tarda PCT. These blisters are usually
seen on the backs of the hands or feet in sun exposed areas. The blisters are firm and take time to burst. They surrounding skin is not
inflammed.
An immunological bullous disease that can look very similar is epidermolysis bullosa acquisita, usually seen at sites of trauma.
A more advanced overview of nearly all possible causes of blisters is shown below. A GP would rarely need to refer to it!
Blisters on the trunk include those on the chest,back and abdomen.
On these areas blisters are usually due to Herpes Zoster (unilateral and painful) bullous staph infection, bullous pemphigoid, plant contact
dermatitis and drugs causing toxic epidermal necrolysis. Pemphigus blisters are fragile and soon form crusts and erosions.
Rarer immunobullous diseases such as dermatitis herpetiformis and linear IgA disease will cause blisters in these areas. Fixed drug eruption
may cause localised blistering.
Management
Culture for bacteria and viruses,
do a Tzanck smear,
do a gram stain and biopsy and immunofluorescence if you consider an immunobullous disease is likely.

Herpes Zoster
SIGN DIP MEN Overview of Blisters

S-Squamous
Bullous Dariers disease,
Bullous Lupus erythematosus
I-Infective
Impetigo,
Staph scalded skin syndrome,

Bullous pemphigoid

Plant contact

P-Physical
Friction blister,
Burns,
Insect bite reaction,
Bullous scabies, Lymphedema,
Puva blisters,
Tanning bed Pseudoporphyria,
Polymorphous light eruption,
Edema blisters of the leg,
Sucking blisters in neonates,
Epidermolysis bullosa,
M Metabolic Porphyria cutanea
tarda,
Diabetes mellitus
Amyloidosis,
Blisters of hemodialysis,
Mastocytosis,
E Endocrine Hypothyroidism,
N Nutritional Pellagra,
Acquired zinc deficiency,
Acrodermatitis enteropathica,

Others
Pompholyx eczema palms and
soles,
Congenital syphilis,
Kindler syndrome,
Neonatal purpura fulminans,
Incontinentia pigmenti,
Bullous ichthyosiform
erythroderma
Hemorrhagic
Blisters pemphigus,
herpes zoster,
leukemia,
lichen sclerosus
Erosions
Pemphigus,
Hailey Hailey,
Eczema herpeticum
Sheets of skin
Staph scalded skin syndrome,
Toxic epidermal necrolysis

Herpes zoster,
Bullous tinea,
Parvovirus B19,
Staph infected varicella,
Bullous orf,
Pseudomonas septicemia,
Hemorrhagic bullae with Vibrio vulnificus,
Mucor infection in immunosupressed,
Blistering dactylitis
G-Granulomatous
N Neoplastic Paraneoplastic pemphigus,
Bullous mastocytosis,
Paraneoplastic pemphigus
D-Drugs
Toxic epidermal necrolysis,
Fixed drug eruption,

Numerous drugs causing the immunobullous disaeases ,


Pseudoporphyria,
Barbiturate coma,
I-Immunological
Plant contact dermatitis,
Phytophoto dermatitis,
Erythema multiforme,
Bullous pemphigoid,
Pemphigus,
Dermatitis herpetiformis,
Linear igA disease,
Chronic bullous dermatosis of childhood,
Bullous lupus,
Mucosal Pemphigoid,
Epidermolysis bullosa aquisita,
Herpes Gestationis,
Lichen sclerosus ,
Bullous morphea,
Bullous necrotising vasculitis

Vesicular
Vesicles are small clear fluid filled deep seated lesions in the epidermis.
Diseases
They are a feature of eczema/ dermatitis when acute in onset but can also be seen in delayed type
hypersensitivity reactions such as a reaction to tinea on the soles of the feet.
They are usually itchy and can subsequently become pustular from secondary bacterial infection. If you have
pustules enquire if they were clear fluid filled lesions initially.
The developement of herpes simplex superimposed on a background atopic eczema is always a diagnostic
problem but look for a sudden painful deteriration in the condition particularly with painful lesions appearing
around the eyes.

Funny
distribution
excluding
Linear

Skin rashes can be found in unusual distributions eg


Flexural
Acral
Photo distribution
Periungual
Periocular
Perioral
Glans penis
Vulva
Solitary localised- This suggests a localised contact dermatitis if red and scaly with a broken
surface or a fixed drug reaction if red and non scaly with slight hyperpigmentation. If recurrent
vesicles preceded by localised pain then herpes simplex is the likeliest diagnosis.

Funny Colour
Excluding red and skin colors we will look at lesions that are an uncommon colour.
YELLOW LESIONS Yellow lesions look yellow because of fat, sebaceous material, carotene, jaundice pigment or drugs. At one stage resolving
bruises go through a yellow phase. Yellow papules or nodules are Xanthomas, xanthogranulomas including necrobiotic, Sebaceous

hyperplasia and other sebaceous tumours, Gouty tophi around elbows and knees.
Yellow skin consider carotene pigmentation of palms and soles, jaundice from any cause and drugs such as quinacrin.
PURPLE LESIONS
Purple lesions are that colour because of altered or venous blood, overgrowth of blood vessels or infiltrates of neutrophils or
lymphocytes into the skin. Consider therefor haemangiomas, angiosarcomas, Kaposi's sarcoma, port wine stains or other
vascular malformations, vasculitis with leaked blood cells, lymphocytoma, lymphoma, and the plaques and nodules of Sweet's
syndrome where the infiltrating cells are lymphocytes. Sarcoidosis can also have a purple colour in the skin. Better also
consider drugs giving a lichenoid drug reaction eg Thiazides and of course Lichen planus itself with itchy papules at the wrists
and lower legs.
GREEN LESIONS
There are not many green lesions in the skin. Copper bracelets can cause green staining under them. Thereafter it would need
to be exogenous pigmentation from a dye. Do not know any drugs causing a generalised green skin colour.
BLUE LESIONS
Things appear blue in the skin if melanin is in the upper dermis or below. It has something to do with light scattering by the
tissues. The same melanin higher in the epidermis shows as black. Venous blood is also blue as is the drug minomycin or
clofazimine when they are deposited in the skin. Blue papules are blue nevi , melanoma metastases, leukaemic deposits or
some lichen planus papules. Blue nodules in neonates are due to severe viral infections with extramedullary haematopoesis or
neuroblastoma metastases!
Cyanosis makes you blue as well!
GREY LESIONS
Again consider drugs such as Minocycline and post inflammatory hyperpigmentation particularly with fixed drug reactions and
lichen planus. It is usually due to melanin in melanophages in the dermis.

Hair problems

Localised hair loss has three common possibilities, alopecia areata, tinea capitis and trichotillomania.

In alopecia areata the area of hair loss is complete, the involved area is smoothe and the hairs may be broken at the edges. The bald area is
not inflammed.
In tinea capitis the area is never completely bare, the hairs are broken, there may be scale on the surface and signs of scalp inflammation. In
trichotillomania the hairs may be broken and the pattern of loss is unusual. The scalp may show inflammation around recently traumatically
removed hairs.
Management-Take scrapings if scaly for fungal culture and include a few hairs. Do a hairpull test to see if the hairs around the bare area come
out from the base with a telogen bulb on the end, a feature typical of alopecia areata.
Rare causes-Incontinentia pigmenti, nevus sebaceous, post tick bite, follicular mucinosis, Ofugi' disease, localised morphea, aplasia cutis,
post herpes zoster, meningocoele,
Generalised hair loss The three common causes are androgenetic alopecia, telogen effluvium and generalised alopecia areata.
Androgenetic alopecia is by far the commonest cause in both males and females. Females retain the frontal hair line but get considerable
thinning behind it. Telogen efluvium follows a fever, general anaesthetic, weght loss or coming off the contraceptive pill or warfarin among
other causes. The hair loss is across all the scalp but there are no bald bits! Generalised alopecia areata is a difficult diagnosis as it gives
features similar to telogen effluvium but a scalp biopsy will separate the two conditions. Generalised hair loss is an unfortunate side effect
of chemotherapy for various cancers.
Specific conditions involving the Hair
Attachments Pediculosis capitis, Piedra
Fragile Hair Menke's disease, Monilethrix, Netherton's syndrome, Pili torti, Trichothiodystrophy
Green hair Copper
Heterochromia Flag sign of Kwashiorkor and Marasmus
Lighter colored hair Phenylketonuria
Loose hair Loose anagen syndrome
Silver Grey hair Chediak-Higashi syndrome
Uncombable Felting, Uncombable hair syndrome
White Forelock Piebaldism, Wardenburg's syndrome
Whitening Canites
Whorled Scalp whorls

Nail problems
There are a variety of common conditions that patients bring to their doctor's attention.
Longitudinal ridging is a normal feature of aging. Splitting of the ends of the nails is due to trauma and too much water exposure.
Separation of the nail from the nailbed is also due to excess wet work where the bonds between the nail and the underlying nail bed are
weakened and the nail separates. This is known as onycholysis.
Any candida found under the separated nail is a contaminant.
Nails are solid keratin which is the food for dermatophyte fungii.
Hence most crumbly nails are due to a dermatophyte infection but some may be due to psoriasis. Take nail clippings for culture. Nail
distortion is
commonly due to
ageing and poorly
fitting shoes.
Specific conditions
involving the nails
Brittle
Brittle nails
Curved
Koilonychia,
Pincer nails
Dystrophic
Darier's
disease,
Lichen
striatus,
Psoriasis,

Onychomycosis,
Onychophagia,
Proximal subungual onychomycosis,
Trachyonychia,
Groove
Digital mucous cyst
Malaligned
Congenital malalignment
Onycholysis
Onycholysis,(numerous causes, water, photo drug etc),
Onychomycosis,
Psoriasis,
Traumatic,
Epidermolysis bullosa aquisita,
Pemphigus vulgaris,
Acropustulosis of Hallopeau
Pigmentation
Drug induced (AZT, Bleomycin, Methotrexate),
Longitudinal melanonychia
Pits
Alopecia areata
Purpura
Splinter hemorrhages,
Subungual hematoma
Ridges longitudinal
Aging,
Lichen planus,
median nail dystrophy
Ridges

Short

transverse
Beau's lines,
Chronic paronychia,
Habit nail tic deformity,

Brachyonychia
Thickened
Chronic mucocutaneous candidiasis,
nail hypertrophy and Onychogryphosis,
Onychauxis,
Onychomycosis,
Pachyonychia congenita,
Psoriasis
Coloured
Blue (Blue nails drugs or Wilson's disease),
Green (Pseudomonas),
White (Half and half nails, Leukonychia, Muehrcke's lines, Terry's nails,White superficial onychomycosis),
Yellow (Nail discoloration cigarretes,Yellow nail syndrome)
Posterior nail fold
Paronychia,
Chronic candidiasis,
Scleroderma,
Dermatomyositis (ragged cuticles)

Nodules on the face are usually due to tumours, the commonest being basal cell skin cancers, squamous cell skin cancers,
melanoma and Merkel cell skin cancers and atypical fibroxanthomas.
The benign nodules on the face would be sebaceous or dermoid cysts, the latter particularly occurring around the base of the
nose and the eyes, near the embryonic planes. neurofibromas and trichoepitheliomas.
Conditions that cause deposits in the skin can also cause nodules on the face particularly amyloidosis, sarcoidosis and infective
disorders such as leishmaniasis, treated leprosy, TB and rarely tertiary syphilis.
Mycosis fungoides or T cell lymphoma of the skin, B cell lymphoma, Granuloma faciale and Lymphocytoma cutis and
angiosarcomas could all cause nodules on the face.
Management generally a biopsy is necessary to establish the diagnosis of the facial nodule and the tissue should be sent for
culture for atypical mycobacteria and for deep fungal infections if an infective cause is considered.
SIGN DIP MEN Nodules Overview
S-Squamous Many of the infective nodules below will have a rough surface
I-Infective
Deep fungal infections particularly Chromoblastomycosis and Sporotrichosis, Tuberculosis, Atypical
mycobacterial ,Leishmaniasis, Syphilis, Leprosy, Orf, Milkers nodules,
G-Granulomatous Sarcoidosis, Granuloma annulare, Foreign body, Erythema elevatum diutinum, Rheumatoid nodule,
Granuloma faciale, Panniculitis,
N-Neoplastic Benign Tumours such as sebaceous cysts, dermatofibroma, lipoma. More aggresive tumours such as Basal cell
carcinoma, Squamous cell carcinoma, Keratoacanthoma, Metastases, Merkel cell, Melanoma, Atypical fibroxanthoma, Mycosis
fungoides, B cell lymphoma, Lymphocytoma, Angiolymphoid hyperplasia with eosinophilia, Angiosarcoma, Lymphangiosarcoma,
Dermatofibrosarcoma protuberans, Cylindroma
D-Drugs

Iodides, Bromides, Phenytoin, Dapsone

I-Immunological Erythema nodosum , Sweets syndrome, Kimuras disease


P-Physical

Prurigo nodularis, Pyogenic granuloma, Digital myxoid cyst, Chilblains(Perniosis)

M-Metabolic Xanthomas, Gouty tophi, Tumoral calcinosis, Mucinoses


E-Endocrine

Pretibial myxedema,

N-Nutritional
Others
Painful nodules Multiple familial leiomyomas, Spiradenoma, Glomus tumour, Angiolipoma, Blue rubber bleb nevus,
Neuroma, Neurilemmoma, Neurofibroma, Keloid, Granular cell tumour, Dermatofibrosarcoma protuberans, Bleeding into a
dermatofibroma
Yellow Nodules Xanthomas, Xanthogranuloma, Sebaceous nevi, Histiocytosis,
Vascular Looking Nodules Bacilliary angiomatosis, Kaposi's sarcoma, Pseudo Kaposi's sarcoma, Angiosarcoma, Multiple
Glomus tumours, Leukemia cutis, Systemic amyloidosis, Metastatic melanoma, Metastaic Merkels, Sweet's syndrome,
Sarcoidosis, Maffucci's syndrome, Angiolymphoid hyperplasia with eosinophilia, Kimura's disease, multiple Clear cell
acanthomas

Specific conditions involving the face


Acneiform Acne vulgaris,Infantlie acne,neonatal acne,Gram Negative folliculitis,Ofugi's disease,Rosacea,Rosacea
fulminans,Steroid rosacea
Annular Seborrhoeic dermatitis,Secondary syphilis
Blue Drug induced pigmentation(Minocycline,amiodarone,minocycline,chlorpromazine)
Comedones Chloracne, Comedonal acne, Dilated pore of Weiner, Favre-Racouchot syndrome
Crust Impetigo, Pemphigus foliaceus, Pemphigus erythematosus
Cysts Eccrine hidrocystomas, Colloid milium
Hyperkeratotic papule Actinic keratoses
Hypertrichosis Hirsutism
Lipoatrophy Progressive hemifacial atrophy (Parry-Rhomberg syndrome)
Nodules Granuloma faciale, Lymphocytoma cutis, Atypical fibroxanthoma, Epidermal inclusion cyst, Merkel cell
tumour
Pedunculated Rhabdomyomatous mesenchymal hamartoma
Pigmented patches Exogenous Ochronosis, Lentigo maligna melanoma, Melasma Solar lentigo, Spreading
pigmented actinic keratosis,
Pigmented macules Freckles, Patterned inherited lentiginosis of blacks, Xeroderma pigmentosum
Plaque Alopecia mucinosa, Discoid lupus erythematosus, granuloma faciale, Jessners lymphocytic infiltrate,
Lepromatous leprosy, Lupus vulgaris, Sweet,s syndrome, Chronic actinic dermatitis
Red Flushing, Systemic lupus erythematosus
Red scaly Airbourne contact dermatitis,Chronic actinic dermatitis,Discoid lupus erythematosus,Seborrhoeic
dermatitis,
Scars Acne conglobata, Acne excoriee, Neurotic excoriations, Atrophoderma vermiculatum, Keratosis pilaris
atrophicans (Ulerythema opherogenes), Hydroa vacciniforme, Erythroprotoporphyria,
Telangiectasia Crest syndrome