Topics discussed in this Tutorial
Variants of Discoid Lupus
Erythema infectiosum
Radionecrotic ulcers
Nail tumours
Pilomatrixoma
Phlebectasia
Eccrine tumours
Painful Tumours
Syndromes with Connective Tissue Nevi
Clinical types of Discoid Lupus
There is a vascular type with erythema and normal epidermis with infiltration beneath it so you have rosacea like discoid lupus. You can get a reticulated erythema where you get healing with punctate atrophy and telangiectasia. You can get chilblain lupus. There is also Rowell’s lupus, lupus profundus and there is an arteritic type like Degos disease or a disseminated atrophy blanche type may occur. The hyperkeratotic type can be nodular or plaque form. You can get a localised keratoderma of the foot and sometimes of the nose. The atrophic form presents as an annular erythema with an atrophic centre. It is like morphea. You can also get atrophic spindling of the fingers. The pigmented type can show both hyper and hypo pigmentation. So the four types are vascular, hyperkeratotic, atrophic and pigmentation types. Other variants include umbilicated papules on the back leaving acneiform scars or a red purple mottled plaque or even calcification. Around the eyes you can get conjunctival redness, lid erythema and scaling especially of the lower eyelid. Adnexae may be involved with hair and sweat gland loss. On the lips you can have a cheilitis or rarely oral ulcers as a manifestation of lupus. On nails you can have subungual hyperkeratoses or the red blue colouring of the nail plate showing longitudinal striae and crumbling away of the nail. Some GSA Images
The image below is discoid lupus
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| Lupus profundus |
Erythema Marginatum
There is usually a rapid evolution of the rash over two to three hours. It is not itchy. It can be seen in rheumatoid arthritis or Still’s disease with salmon pink macular or papular lesions on the trunk and extremities.
Dermnet on Erythema marginatum
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| Erythema marginatum |
Erythema Infectiosum and Rubella
Both give buccal red macules. Rubella affects the soft palate. There is a prodrome with red macules. 20% show Forchheimer’s sign. Erythema infectiosum gives slight oedema of the face and it lasts longer than rubella. The lesions in Still’s disease are evanescent, salmon pink and non itchy macules.
The image below is erythema infectiosum
Radio Necrotic Ulcers
The radio necrotic ulcer is very painful. Radiotherapy can cause poikiloderma and watch anything that you are going to do surgically to an old x-rayed area including biopsy because it may not heal. These areas may also develop squamous cell skin cancers. Radiotherapy to the scalp can also induce erosive pustular dermatosis as it attempts to heal.
Dermnet on Radiation Dermatitis
The image below is radiation necrosis scalp
The common benign lesions are warts, Koenen’s tumours, periungual digital fibromas, a glomus tumour, keratoacanthoma, pyogenic granuloma, subungual epidermoid inclusion, a nevus, subungual exostosis and an enchondroma. The other benign tumour is a myxoid cyst. This will often cause pressure on the nail plate causing a deformity. The malignant tumours are melanoma and SCC.
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| Periungual fibroma toe |
The image below is of a myxoid cyst
This firm papular lesion can occur in adults. It is usually hard and lobulated. It is normally found in children. There may be occasionally an associated granulomatous reaction if the lesion ruptures. Multiple pilomatrixomas are associated with myotonic dystrophy and the Ehlers Danlos and Gardner’s syndrome.
The image below is a pilomatrixoma of the eyelid
There is fading of the extraoral areas of pigmentation at puberty and polyps are usually in the small bowel. They are usually hamartomas.
Cronkite Canada Syndrome
Patients with this condition can get a nail dystrophy as well as marked alopecia and bowel polyps.
In nevus of Ota you have blue lesions on the sclera and black on the conjunctiva.
Phlebectasia
This does not occur at birth. It can occur as late as late as adolescence. Veins thrombose and recanalise with pigmentation and sometimes ulceration.
Florid Oral Papillomatosis
This is a variant of verrucous carcinoma and it can develop into squamous cell cancer.
Sequences of the Rash in Syphilis
Initially you have macules developing into papules then into papulo squamous lesions. You also can have leukoderma. The lesion never itches and never vesiculates. The nails may present as paronychia. You may get erosions on the tongue and secondary syphilis that looks like geographic tongue.
The image below is of the typical palmar scaly lesions of secondary syphilis
These include hidrocystoma, apocrine hidrocystoma and hidradenoma, these are usually found on the face and are solitary and slow growing, hidradenoma papilliferum, syringo cystadenoma papilliferum and eccrine poroma. The latter is usually on the feet, has a collarette. It is pink. It may be smooth or warty and there is no pain associated with the lesions.
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| Hidradenoma |
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Eccrine hydrocystoma |
This condition usually presents as multiple papules on the hands and fingers but it can occur also in the axillae. The lesions are often reddish brown and granulomatous looking. The condition has a specific histology with an eosinophilic ground glass multinucleated cells with surrounding histiocytes and lymphocytes.
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| Multicentric reticulo histiocytosis |
Painful Tumours
Leiomyoma, glomus tumours, spiradenoma, angiolipoma, Schwannoma and chondrodermatitis nodularis helicis. Glomus tumours can be single and painful and in adults or they can be multiple seen in children mainly on the trunk and extremities. They are not painful and can be familial. You may get painful discolouration and sweating before the eruption of glomus tumours.
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| Glomangioma Syndromes with Connective Tissue Nevi 1 Tuberous sclerosis 2 Goltz syndrome The latter may present as three patterns There often may be other cutaneous manifestations associated with this disease such as striae, keloids and nevi. Note that pseudo xanthoma elasticum is usually found on the flexures.  |
