Topics discussed in this Tutorial
Neuromas
DD of Angiokeratomas
Lipoatrophy DD
Scleroderma of the Hands
Alopecia Mucinosa
Perianal fistulas
Abscesses
Animal contact lesions
DD of an Epidermal nevus
Streptococcal infections
Keratoacanthomas
DD of upper respiratory Obstructions
Cysts with clear fluid
Sarcoidosis of the face
Neuromas
There is the schwanoma, the neurofibroma which can be both syndromal and non-syndromal, neurofibrosarcoma and cutaneous meningioma. Another name for a swannoma is a neurilemmoma.
The histiocytoses are described as histiocytosis X types and the non X. The non X include benign cephalic histiocytosis, juvenile xanthogranuloma, self limiting benign histiocytosis, generalised disseminated histiocytosis, xanthoma disseminatum and multicentric reticulo histiocytosis.
The differential diagnosis of angiokeratomas includes angiokeratoma circumscriptum, Fabry’s disease, Mibelli’s disease that is seen in females with acrocyanosis of the feet and hands and angiokeratoma Fordyce
The image below is of benign cephalic histiocytosis. courtesy of Dr Nameer Al Sudany
Lipoatrophy Differential Diagnosis
There is a localised panatrophy, localised fat atrophy, symmetrical partial atrophy and syndromal atrophy.
The image below is of lipodystrophy See source
Scleroderma of the Hands
The differential diagnosis is scleroatrophic syndrome of Huriez. There is no Raynaud’s and it is a familial condition. Lichen myxedematosus, juvenile diabetes, amyloid and drugs such as Bleomycin, Lavamizole and vinyl chloride disease. There is also acrogeria, shoulder hand syndrome and phenyl ketonuria.
Scleroderma of the neck is scleredema, PCT and the carcinoid syndrome.
Alopecia Mucinosa
This can be the localised plaque type, generalised plaque type or mycosis fungoides plaques.
The image below is from the article linked above on the Scleroatrophic syndrome of Huriez See these other examples in GlobalSkinAtlas
Perianal Fistulas
Consider Crohn’s disease and also hidradenitis suppurativa. Fistulas in the neck consider scrofuloderma and branchial fistulas. Fistulas on the face consider nasal, lip, ear and dental.
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| Perianal Crohn's disease |
The image below is of scrofuloderma courtesy of Dr Nameer Al Sudany
Lymphadenopathy
Rapid onset of lymphadenopathy occurs in infectious mononucleosis, syphilis, Hodgkin’s disease and leukaemia.
Abscesses
These are divided into Animal contact such as glanders and necrobacillosis or Travellers such as tularaemia, plague or melioidosis and Surgical or immunosuppressed such as gangrenous cellulitis, protothecosis and Jobs syndrome and then the Rest including bacterial folliculitis or furunculosis, carbuncles, salmonella, mycobacterium fortuitum and botryomycosis.
Animal Contact Lesions
These include conditions such as orf, cat scratch disease, plaque, erysipelothrix, pasturella multocida, listeriosis, anthrax, tularaemia, necrobacillosis and glanders.
The Differential Diagnosis of an Epidermal Nevus
This includes ILVEN, Conradi’s disease, epidermal hyperkeratosis, epidermodysplasia verruciformis, ichthyosiform erythroderma, incontinentia pigmenti and also the epidermal nevus syndrome.
The image below is an ILVEN
Streptococcal Infections
Watch ecthyma and also streptococcus viridans causing sub-acute bacterial endocarditis. There is also strep millieri associated with hidradenitis suppurativa.
Compare acnitis versus acne necrotica versus a tuberculid.
In Acnitis the active lesions are on the forehead, it scars and there is pigmentation. In Acne necrotica it is umbilicated, there is itch and it goes through many stages quickly but a tuberculid stays a while and is usually seen on the elbows.
The image below is of acne necrotica
Milia
Question
What are the types of milia?
Answer
There is the congenital type as seen in epidermolysis bullosa and Marie una hypotrichosis. It is familial when it is an autosomal dominant. There are milia after trauma particularly dermabrasion, there are milia after bullae heal particularly epidermolysis bullosa dystrophica and porphyria cutanea tarda and there are milia associated with congenital ectodermal defects.
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| Milia in EBA after blisters heal |
Types of Keratoacanthomas
There is the solitary type but there are the atypical forms for example keratoacanthoma centrifugum or coral reef keratoacanthomas or giant keratoacanthomas. There is the multiple Ferguson Smith self healing epithelioma and there are the eruptive keratoacanthomas which are generally very small sparing the palms and soles and associated with severe pruritus. Multiple small eruptive KAs have also been reported in red tattoos.
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| Keratoacanthoma centrifugum Image of Dr John Rowlands |
Differential Diagnosis of Obstruction of the Upper Respiratory Tract
Rhinoscleroma presents as an atrophic rhinitis followed by an infiltrative stage and later the larynx can be involved and patients can die from respiratory asphyxia. There is Wegener’s granulomatosis, there is lethal midline granuloma, there is mucocutaneous leishmaniasis, South American blastomycosis which generally affects the lung with dissemination but there is a mucocutaneous type with perioral abscesses and lymphadenopathy. North American blastomycosis has a granular appearance and there is a sporotrichoid type, chromomycosis type and a bromoderma type. It often has central clearing with white peripheral scars.
Rhinosporidiosis
This gives rise to cauliflower like masses in the nose or the mouth and should be differentiated from tertiary syphilis, nasal TB, lymphoma or neoplasms, yaws and leprosy.
The image below is of North American Blastomycosis
Cysts that Present with Clear Fluid
They are either due to impetigo or hidrocystomas. Fox Fordyce disease can affect the axillae but often there is itch only at first and it may be seen around the nipples provoked by emotion and has a prolonged course.
It is usually circumscribed, it can be solitary but may be grouped. Rarely it has a hyperkeratotic surface like lupus and it may also cause a temporary alopecia in males. Jessners lymphocytic infiltrate in contrast is usually pink, red to brown in colour, can be annular and it is not circumscribed
View the image below at source
Sarcoidosis affecting the face
The types that you see are the plaque type which is rare, the angiolupoid type, lupus pernio particularly in the nose or the ears, a papular type and an annular on the forehead and also a scar sarcoid.
View the image below at source
