Topics discussed in this Tutorial.
Leg ulcers, Papules face, Eosinophilic syndromes, Central clearing syndromes, Vegetating lesions dd, Oral ulcers, Histiocytosis syndromes, Hypermelanosis circumscribed, Cold lesions, Paraproteinaemias,
The Differential Diagnosis of Leg Ulcers
Leg ulcers can be arteritic, venous ,undermined due to surrounding disease, tumour, neuropathic with trauma due to anaesthetic skin, infective plus or minus lymphadenopathy. The mnemonic AEST TAIL is sometime used. In an elderly individual always consider diabetes and skin malignancy.
The image below is a neuropathic ulcer in a diabetic.
Monomorphic Papules on the face
If they are infiltrates they are amyloid and lipoid proteinosis. If they are tumours they are trichilemomas, trichoepitheliomas, adenoma sebaceum and syringomas.
Grouped Monomorphic Micro Papules on Face
Consider lichen nitidus, lichen scrofuloderma, lichen myxoedema, follicular mucinosis, follicular eczema, lichenoid sarcoid, keratosis pilaris and micropapular granuloma annulare or granulomatous rosacea.
The image below is of lipoid proteinosis. Infiltrates are seen along the eyelid margin and the patient has associated hoarseness.
Eosinophilic Syndromes
If there are systemic causes then usually the skin is not involved. However cutaneous eosinophilic syndromes include insect bites, scabies, drugs, atopy, hyper eosinophilic syndrome, transient neonatal erythema, Ofugi’s disease, job’s syndrome, Well’s syndrome, incontinentia pigmenti, Kimura’s disease, and eosinophilic panniculitis.
Comment Eosinophilic pustular folliculitis- 3 types Classic eosinophilic pustular folliculitis (Ofuji disease) 1. Typically occurs in Japanese patients, who have chronic, recurrent follicular pustules, with a tendency to form circinate plaques, in a seborrheic distribution
2. Eosinophilic pustular folliculitis associated with immunosuppression.Most often occurs in patients with human immunodeficiency virus infection, who have severely pruritic papules of the face and upper trunk
3. Eosinophilic pustular folliculitis of infancy/neonatal period. Follicular pustules of the scalp. Tendency for recurrences and chronicity (except eosinophilic pustular folliculitis of infancy) Characterized by follicular and perifollicular eosinophil infiltration Associated with peripheral blood eosinophilia.
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| Deckchair sign Papuloerythroderma of Ofugi |
The image below is of Kimura's disease dermal nodule rich in eosinophils
Syndromes with Central Clearing
Consider SIGN DIP. The S for squamous includes pityriasis rubra pilaris, psoriasis and subacute lupus erythematosus. The I for infective includes impetigo and a fungal infection. The G for granulomatous includes syphilis, leprosy, granuloma annulare and sarcoidosis. The N for malignancy includes some regressing melanomas, lymphoma and basal cell carcinoma especially the superficial type. Infiltrates with central clearing include lymphocytic infiltrates such as Jessner’s, neutrophilic such as Sweet’s syndrome and eosinophilic infiltrates such as Well’s syndrome or Ofugi’s disease. Pustular conditions with central clearing include subcorneal pustular dermatosis, the erythemas include erythema annulare centrifugum, erythema marginatum and acrodermatitis chronica atrophicans. The epidermal syndromes with central clearing include Hailey Hailey disease.
The differential diagnosis of vegetating lesions include SIGN DI HILL and the HILL stands for hereditary, intertrigo, lymphedema and lymphoma.
Clinically when I see a big vegetating plaque on an arm or leg I immediately think of Chromoblastomycosis which is shown in the image below.
Oral Ulcers
On the palate it may be pemphigus. On the buccal mucosa it is pemphigoid. On the gingiva it is cicatricial pemphigoid. Kawasaki’s disease, toxic shock syndrome, staph, scalded skin syndrome and toxic epidermal necrolysis all may affect the inside of the mouth as may lichen planus and acute erythema multiforme.
The image below is of Cicatricial pemphigoid involving the hard palate just to be awkward!
Histiocytoses Both X and non-X Age associations
At three months it is self-healing histiocytosis and it may last two to three months. At six months it is benign cephalic histiocytosis and it may last two to three years. In infants it is juvenile xanthogranuloma. Aged more than 20 it is sinus histiocytosis with massive lymphadenopathy. In adults it is xanthoma disseminatum or generalised eruptive histiocytosis or papular xanthoma and in older people it is multicentric reticulo histiocytosis and progressive nodular histiocytosis.
This list is taken from Fitzpatrick. The lesions of histiocytosis are papular , red/yellow in colour, usually in flexures and the scalp. Vesicles and pustules can be seen especially in the neonatal period. The presence of purpura in lesions is a poor prognostic sign.
Note that early pyoderma grangrenosum lesions can look like orf, anthrax can look like ecthyma grangrenosum, Majocchi’s can look like vasculitis on the legs and watch papulo squamous syphilid which can look a bit like pityriasis lichenoides or lymphomatoid papulosis.
The image below is of Histiocytosis X a tumour of Langerhans Cells
Localised Hyperpigmentation
DAMN standing for drugs, autoimmune, metabolic and neoplastic. PIG standing for post inflammatory, infective and genodermatoses. PAPA standing for pigmented purpuric dermatosis, amyloid, parapsoriasis and acanthosis nigricans. The metabolic causes of localised hyperpigmentation are ochronosis, chloasma and porphyria cutanea tarda.
Clinically localised hyperpigmentation should have you thinking about a fixed drug reaction or morphoea if on the trunk and a pigmented purpuric dermatosis if on the lower leg where the pigmentaion is due to hemosiderin from extravasated red cells..
Circumscribed hypermelanosis
• nevus of Hori • lentigo • Becker’s nevus • ephelides • post-inflammatory hyperpigmentation • familial periorbital hyperpigmentation • partial unilateral lentiginosis • erythema ab igne • prurigo pigmentosa • xanthoma planum • inherited pattern lentiginosis in blacks • acquired brachial cutaneous dyschromatosis • Riehl melanosis • cutaneous amyloidosis • Laugier-Huinziker syndrome • atrophoderma of Pasini-Pierini • fixed drug eruption • erythema dyschromicum perstans
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| Erythema dyschromicum perstans |
The thing to remember about it is it is five of everything. Five lesions namely papular, hypertrophic, atrophic, pigmented and bullous. Five shapes guttate, plaque, confluent, annular and linear. Five sites hair, palms, soles, nails, mucus membranes and face with lichen planus actinicus. Associated diseases include drugs, colour film exposure, graph versus host, lichen planus and lupus erythematosus, lichen nitidus and Nekams disease.
The image below is LP back
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| Lichen planus actinicus |
Perforating Disorders
They are primary or secondary. The primary causes are elastosis perforans serpiginosa, reactive perforating collagenosis and uraemic follicular keratoses. A lot of other conditions can perforate or eliminate tissue through the epidermis from the dermis. eg perforating granuloma annulare particularly on the fingers and some deep fungal or mycobacterial infections.
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| Perforating Kyrle's disease |
Cold Lesions Infantile cold lesions include cold injury, sclerema and fat necrosis of the newborn. Excess cold exposure gives frostbite and trench foot. Single tissue disease gives cold erythema, cold urticaria and cold panniculitis. Blood problems can be due to cryoagglutins, cryoglobulins and cryoprecipitins and the seven syndromes are perniosis, livedo reticularis, Raynaud’s, acrocyanosis, erythrocyanosis and Rowell’s syndrome which is erythema like lesions plus or minus perniosis and vasculitis or Lupus erythematosus. The image below is cold vasculitis  Other Diseases with Multiple Myeloma Like Blood Features Include amyloid, plasmacytoma and cryoglobulinemia. Other Diseases with Paraproteinemia’s Include scleredema, scleromyxedema, necrobiotic xanthogranuloma, Sweet’s syndrome, pyoderma gangrenosum and epidermolysis bullosa acquisita. The other one is subcorneal pustular dermatosis. The image below is necrobiotic xanthogranuloma  | |
These were some of Ken Paver’s Favourite slides and if you have a visual imagination you can see how I would get them wrong.
The blue lower leg due to phlegmasia caerulea dolens.
The claw like hand with traumatised nails due to syringomyelia.
The insect bitten leg actually due to follicular perniosis.
The dripping urticaria due to cold shower urticaria.
The carcinomatosis erysipelas looking like a plant contact dermatitis.
Malignant syphilis, the blonde haired boy with bad impetigo.
The atypical childhood PRP looking like ichthyosis vulgaris on the face.
The fat child with red/blue face and arms due to a cold injury.
The lichen plano pilaris slide looking like Darier’s or transient acantholytic dermatosis.
The image below is of Cold Urticaria
