Painful nodules of the leg
Conditi ons with central umbilication
The causes of macroglossia
Recurrent pyodermas
Questions will also be asked on the following conditions: Painful Nodules
Causes of palmar pits
Causes of pruritic papules
Lymphangioma circumscriptum
Bowenoid papulosis
Papular urticaria
Erythema nodosum
Painful Nodules on the Leg
Erythema nodosum - It is usually on the shins, it crops, it is tender and there is bruising Image
Subacute nodular migratory panniculitis - Similar features to erythema nodosum but the lesions are more spreading and can continue to grow over a six week period or longer
Polyarteritis nodosa - This shows livedo with nodules more likely in a cutaneous variant where it is seen along vessels Image
Erythema induratum - Seen in an older female age group it is often painful with no ulceration but associated stasis and thrombosis. In a younger age group of females there is usually no pain but ulceration and erythrocyanosis.
Nodular vasculitis - Usually seen in women in the 30 to 60 years age group on the legs. Symmetry is unusual. They are usually tender small nodules which may ulcerate, but if not will slowly disappear. This can be a cyclic eruption for several years. Image
Erythrocyanosis with perniotic nodules
- These occur usually in fat young women who ride horses and typically the lesions are seen on the buttocks as well as the legs. They seldom ulcerate. Image
Panniculitis
- If associated pancreatic disease there is abdominal pain. Generally these lesions are painful. The patient is febrile. They may be quite extensive and there is usually less bruising than erythema nodosum.
Leprosy - Can rarely give painful nodules in the leg in the course of a lepromatous reaction.
The image below is of Sweet's Syndrome
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| Sweets syndrome Purple nodules mildly tender Neutrophilic dermatosis |
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| Pancreatic panniculitis Tender Often bursts Lobular panniculitis |
Recurrent Pyodermas
- Pyoderma is a rather non-specific term. It refers to lesions produced by pus producing bacteria and can take the form of pustules, crusts or ulcers. Often there is a background problem such as atopic dermatitis, scabies, infected insect bites, herpes simplex, contact dermatitis or resolving impetigo. However it may hide underlying disorders such as leukaemia in infants and neonates. There are a variety of immunological disorders that may present with pyoderma. These are listed below. Some of them have associated atopic dermatitis like features particularly the Wiskott-Aldridge syndrome and Job's syndrome.
Medscape review of this topic at recentAAD Meeting
Letterer-Siwe histiocytosis may have accompanying pyoderma and look like infected seborrhoeic dermatitis. Image
Note the take home message is that pyoderma and eczema in the newborn and neonate should also make you consider some of these congenital immuno deficiencies or blood diseases and histiocytosis.
Recurrent Pyodermas -Congenital
Immunological disorders
Chronic granulomatous disease
Chediak Higashi
Wiskott Aldridge
Brunton's Agammaglobulinemia Ataxia telangiectasia
Cyclic neutropenia
Others
Behcet's
Letterer-Siwe histiocytosis
Vasculitis
Job's Syndrome
eMedicine-Chronic granulomatous disease eMedicine-Wiskott-Aldridge syndrome eMedicine-Job's Syndrome GSA-Langerhans cell histiocytosis
Lecture on Histopathology of Histiocytoses
The image below is of Disseminated Histiocytosis
Pruritic Papules
The commonest pruritic papules are those seen in atopic eczema. Often these papules will coalesce to form areas of lichen simplex. However individual pruritic papules are commonly seen in Grover's syndrome and scabies.
As well as the conditions listed below, unusual papular eruptions can be seen in the viral exanthem Gianotti-Crosti syndrome and also as a dermatophytid seen as a systemisation of an underlying fungal infection and an unusual rash called a Pediculid which is an Id reaction seen in 25% of cases with Pediculosis capitis. The rash is a fine skin coloured papular rash on the back and arms. It clears rapidly after treatment of the scalp.
Pruritic Papules
Lichen planus
Dermatitis herpetiformis
Scabies
Papular urticaria
Grover's disease
Fox-Fordyce Disease Image
Prurigo Nodularis
GSA-Lichen planus Dermis Atlas-Dermatitis herpetiformis
eMedicine-Dermatitis herpetiformis eMedicine-Fox-Fordyce disease
Papular Urticaria
Grouped urticarial papules or papulo vesicles sometimes in a row are a feature of hypersensitivity reactions to the bites of various insects eg fleas, mosquitoes and bed bugs.
Palmar Pits
Palmar pits are often very subtle and you have to look carefully to see them. The commonest condition in which they will occur will be the basal cell nevus syndrome but more generalised holes in the soles of the feet will be seen in pitted keratolysis where a corney bacteria has digested keratin on the soles of the sweaty feet. Causes of Palmar Pits
Basal cell naevus syndrome
Cowden's Syndrome
Darier's Disease
Pitted Keratolysis on the soles
Acrokeratosis verruciformis and
Porokeratosis
GSA-Basal cell nevus syndrome GSA-Pitted keratolysis GSA-Darier disease
The image below is of Pustular Scabies
Painful Nodules on the Skin
The more esoteric painful nodules are listed below, but of course foreign body reactions or chilblains would be much more common that any of them. One should also not forget chondrodermatitis nodularis helicis on the edge of the ear where necrotic cartilage is trying to be expelled through the skin.
Of the more esoteric ones below, leiomyomas are often painful in the cold.
Painful Nodules in the skin
Leiomyoma
Angiolipoma
Glomus tumour
Eccrine Spiradenoma
Neurilemmomas
Neuromas
Blue rubber bleb nevi
Keloids
Granular cell tumour
Dermatofibrosarcoma Protuberans
Question What is the differential diagnosis of multiple glomus tumours?
Answer--Blue rubber bleb nevus, cavernous haemangiomas, leiomyomas, venous malformations, lymphoma, leukaemia cutis, angiosarcoma, Kaposi's sarcoma, metastatic carcinoma, dermatofibrosarcoma protuberans, and pseudolymphoma.
eMedicine-Leiomyoma eMedicine-Blue rubber bleb nevi
The image below is of multiple Leiomyomas
Palmoplantar Keratodermas
In trying to differentiate the underlying diagnosis of palmoplantar keratoderma that appears to be inherited, it is important to look in the mouth for evidence of leukokeratoses and examine the nails and also whether the patient sweats or not. A biopsy is helpful in differentiating epidermolytic palmoplantar keratoderma from the Unna-Thost type.
The Unna-Thost type involves the palms, soles and occasionally the knees. Pachyonychia congenita has massively thickened nails. Howel-Evans' syndrome is associated with oesophageal carcinoma.
The inherited types of palmoplantar keratoderma
Unna Thost
Dyskeratosis Congenita
Pachyonychia Congenita
Hidrotic Ectodermal Dysplasia
Darier's Disease
Naegeli's Syndrome
eMedicine-Pachyonychia congenita eMedicine-Palmoplantar Keratodermas
Question What syndromes have palmoplantar keratoderma as an assosciated feature?
Answer Syndromes with palmoplantar keratoderma as an assosciated feature
Conditions with Central Umbilication
Sebaceous hyperplasia
Viral vesicles-Varicella
Molluscum contagiosum
Degos Syndrome
Cryptococcosis
Generalised lichen planus
Kyrle's Disease
The image below is of multiple Leiomyomas
Palmoplantar Keratodermas
In trying to differentiate the underlying diagnosis of palmoplantar keratoderma that appears to be inherited, it is important to look in the mouth for evidence of leukokeratoses and examine the nails and also whether the patient sweats or not. A biopsy is helpful in differentiating epidermolytic palmoplantar keratoderma from the Unna-Thost type.
The Unna-Thost type involves the palms, soles and occasionally the knees. Pachyonychia congenita has massively thickened nails. Howel-Evans' syndrome is associated with oesophageal carcinoma.
The inherited types of palmoplantar keratoderma
Unna Thost
Dyskeratosis Congenita
Pachyonychia Congenita
Hidrotic Ectodermal Dysplasia
Darier's Disease
Naegeli's Syndrome
eMedicine-Pachyonychia congenita eMedicine-Palmoplantar Keratodermas
Question What syndromes have palmoplantar keratoderma as an assosciated feature?
Answer Syndromes with palmoplantar keratoderma as an assosciated feature
Conditions with Central Umbilication
Sebaceous hyperplasia
Viral vesicles-Varicella
Molluscum contagiosum
Degos Syndrome
Cryptococcosis
Generalised lichen planus
Kyrle's Disease
Conditions with Central Umbilication
These are a mixed group with sebaceous hyperplasia probably being the commonest. Note the similarity morphologically between disseminated cryptococcosis and molluscum contagiosum. The disseminated cryptococcosis is most likely to be seen in an HIV or other immunosuppressed patient presenting with fever and headache.
eMedicine-Cryptococcosis eMedicine-Degos syndrome
The image below is of Pachyonychia Congenita
Lymphangioma Circumscriptum
This is now usually called superficial lymphatic malformation presenting as deep seated vesicle like papules resembling frog spawn. The colour can vary from yellowish through pink, red or dark depending on the amount of blood in the lesions. Note that many of these lesions may have a deep component that occupies subcutaneous tissue and even muscles. An MRI should be done to assess the extent. A CO2 laser is useful provided there are no deeper components.
GSA-Lymphangioma eMedicine-Lymphangioma circumscriptum
Note-In the differential diagnosis of pyogenic granuloma, always include Kaposi's sarcoma, eccrine poroma, malignant melanoma and merkel cell tumour.
eMedicine-Eccrine poroma
The image below is of Lymphangioma Circumscriptum
Erythema Nodosum
Erythema nodosum usually gives rise to painful red tender papules or nodules on the legs particularly over the shins. There is often surrounding bruising as they involute. The lesions can occur in crops. Ulceration does not occur and the lesions usually resolve without atrophy or scarring. Look for an association with sarcoidosis and drugs particularly bromides, iodines and sulfonamides. Oral contraceptives are currently the most common drug inducing erythema nodosum.
GSA-Erythema nodosum eMedicine-Erythema nodosum
The image below is of Erythema Nodosum
Causes of Macroglossia
Tumour
Thiamine deficiency
Systemic amyloidosis
Hypothyroidism
Angioedema
Interstitial glossitis
Pemphigus vulgaris
Melkersson-Rosenthal syndrome
Haemangioma of the tongue
The image below is of Systemic Amyloidosis
Bowenoid Papulosis
These lesions are often hyperpigmented flat papules seen in groups particularly on the penis or perianally. Histology shows cellular atypia similar to Bowen's disease. They are usually caused by HPV 16.
eMedicine-Bowenoid papulosis
Question- Bowenoid papulosis on glabrous skin is less likely to show malignant change than the same lesions on mucosal skin. True or False?
Answer - True. On glabrous skin Bowenoid papulosis behaves almost like normal warts but on mucosal surfaces of the glans penis may have an increased risk of forming squamous cell skin cancers.
