Chapter A4: Atlas of Skin Manifestations of Internal Disease

Acne vulgaris, with inflammatory papules, pustules, and comedones. (Courtesy of Kalman Watsky, MD; with permission.)

Acne rosacea, with prominent facial erythema, telangiectases, scattered papules, and small pustules. (Courtesy of Robert Swerlick, MD; with permission.)

Psoriasis. A. Typical psoriasis is characterized by well defined small and large erythematous plaques with adherent silvery scale. B. Acute inflammatory variants of psoriasis may present with widespread superficial pustules.

Atopic dermatitis, with ill-defined hyperpigmentation, lichenification, and scaling in the antecubital fossae. (Courtesy of Robert Swerlick, MD; with permission.)

Dyshidrotic eczema, characterized by deep-seated vesicles and scaling on palms and lateral fingers, is often associated with an atopic diathesis.

Seborrheic dermatitis, with erythema and scale in the nasolabial fold. (Courtesy of Robert A. Swerlick, MD; with permission.)

Stasis dermatitis, with erythematous, scaly, and oozing patches over the lower leg. Several stasis ulcers are also seen in this patient.

Allergic contact dermatitis. A. Acute phase, with sharply demarcated, weeping, vesicular plaques in a perioral distribution. B. Allergic contact reaction to nickel, chronic phase, with an erythematous, lichenified, weeping plaque on skin chronically exposed to a metal snap. (B: Courtesy of Robert Swerlick, MD; with permission.)

Lichen planus, with multiple flat-topped, violaceous papules and plaques. Nail dystrophy, as seen in this patient’s thumbnail, may also be a feature. (Courtesy of Robert Swerlick, MD; with permission.)

Seborrheic keratoses are “stuck on,” waxy, verrucous papules and plaques with a variety of colors ranging from light tan to black.

Vitiligo in a typical acral distribution, with striking cutaneous depigmentation as a result of melanocyte loss.

Alopecia areata, characterized by a sharply demarcated circular patch on the scalp. Histologically, alopecia areata is not devoid of hairs—they are smaller and more likely in telogen phase. Preservation of follicular orifices is indicative of nonscarring alopecia. (Courtesy of Robert Swerlick, MD; with permission.)

Pityriasis rosea. Multiple round or oval erythematous patches with fine central scale are distributed along the skin tension lines on the trunk.

A. Urticaria, with characteristic discrete and confluent, edematous, erythematous papules and plaques. B. Dermatographism. Erythema and whealing developed after firm stroking of the skin. (B: Courtesy of Robert Swerlick, MD; with permission.)

Epidermoid cysts. Several inflamed and noninflamed firm cystic nodules are seen in this patient. Often a patulous follicular punctum is observed on the overlying epidermal surface.

Keloids resulting from ear piercing, with firm exophytic flesh-colored to erythematous nodules of scar tissue.

Cherry hemangiomas—multiple erythematous to dark-purple papules, usually located on the trunk—are very common and arise in middle-aged to older adults.

Frostbite of the hand, with vesiculation surrounded by edema and erythema. (Courtesy of Daniel F. Danzl, MD; with permission.)

Frostbite of the foot, with vesiculation surrounded by edema and erythema. (Courtesy of Daniel F. Danzl, MD; with permission.)

Kaposi’s sarcoma in a patient with AIDS. Patch, plaque, and tumor stages are shown.

Non-Hodgkin’s lymphoma involving the skin, with typical violaceous, “plum-colored” nodules. (Courtesy of Jean Bolognia, MD; with permission.)

Basal cell carcinoma, with central ulceration and a pearly, rolled, telangiectatic tumor border.

Mycosis fungoides is a cutaneous T-cell lymphoma. Patch and Plaque-stage lesions are seen in this patient.

Metastatic carcinoma to the skin is characterized by inflammatory, often ulcerated dermal nodules.

Keratoacanthoma is a low-grade squamous cell carcinoma that presents as an exophytic nodule with central invagination and keratinous debris.

Squamous cell carcinoma is seen here as a hyperkeratotic, crusted, and eroded plaque on the lower lip. Sun-exposed skin of the head, neck, hands, and arms are other typical sites of involvement.

Actinic keratoses consist of hyperkeratotic, erythematous papules and macules on sun exposed skin. They arise in middle-aged to older adults and have some low potential for malignant transformation. (Courtesy of Robert Swerlick, MD; with permission.)

Nevi are benign proliferations of nevomelanocytes characterized by regularly shaped hyperpigmented macules or papules of a uniform color.

Dysplastic nevi are irregularly pigmented and shaped nevomelanocytic lesions that may be associated with familial melanoma.

Superficial spreading melanoma, the most common type of melanoma, is characterized by color variegation (black, blue, brown, pink, and white) and irregular borders.

Lentigo maligna melanoma occurs on sun-exposed skin as a large, hyperpigmented macule or patch with irregular borders and variable pigmentation. (Courtesy of Alvin Solomon, MD; with permission.)

Nodular melanoma most commonly manifests as a rapidly growing, often ulcerated or crusted black nodule. (Courtesy of S. Wright Caughman, MD; with permission.)

Acral lentiginous melanoma is more common among blacks, Asians, and Latinos and occurs as an enlarging hyperpigmented macule or patch on the palms or soles. Lateral pigment diffusion is present.

Erysipelas is a streptococcal infection of the superficial dermis and consists of well-demarcated, erythematous, edematous, warm plaques.

Varicella, with numerous lesions in various stages of evolution: vesicles on an erythematous base, umbilicated vesicles, and crusted papules.

Herpes zoster is seen in this HIV-infected patient as hemorrhagic vesicles and pustules on an erythematous base in a dermatomal distribution. (Courtesy of Robert Swerlick, MD; with permission.)

Impetigo is a superficial streptococcal or Staphylococcus aureus infection consisting of honey-colored crusts and erythematous weeping erosions. Bullous lesions are occasionally seen.

Tender vesicles and erosions in the mouth of a patient with hand-foot-and-mouth disease. (Courtesy of Stephen D. Gellis, MD; with permission.)

Lacy reticular rash of erythema infectiosum (fifth disease).

Molluscum contagiosum is a cutaneous poxvirus infection characterized by multiple umbilicated flesh-colored papules. (Courtesy of Yale Resident’s Slide Collection; with permission.)

Oral hairy leukoplakia often presents as white plaques on the lateral tongue and is associated with Epstein-Barr virus infection. (From K Wolff et al: Fitzpatrick’s Color Atlas & Synopsis of Clinical Dermatology, 5th ed. New York, McGraw-Hill, 2005. www.accessmedicine.com.)

Fulminant meningococcemia, with extensive angular purpuric patches. (Courtesy of Stephen D. Gellis, MD; with permission.)

Rocky Mountain spotted fever, with pinpoint petechial lesions on the palm and volar aspect of the wrist. (Courtesy of Robert Swerlick, MD; with permission.)

Erythema migrans, the early cutaneous manifestation of Lyme disease, is characterized by erythematous annular patches, often with a central erythematous papule at the tick-bite site. (Courtesy of Yale Resident’s Slide Collection; with permission.)

Primary syphilis, with a firm, nontender chancre. (Courtesy of Gregory Cox, MD; with permission.)

Secondary syphilis commonly affects the palms and soles, with scaling, firm, red-brown papules. (Courtesy of Alvin Solomon, MD; with permission.)

Condylomata lata are moist, somewhat verrucous intertriginous plaques seen in secondary syphilis. (Courtesy of Yale Resident’s Slide Collection; with permission.)

Secondary syphilis, with the characteristic papulosquamous truncal eruption.

A. Tinea corporis is a superficial fungal infection, seen here as an erythematous annular scaly plaque with central clearing. B. A common presentation of chronic dermatophyte infection involves the feet (tinea pedis), hands (tinea manum), and nails (tinea unguium).

Scabies, with typical scaling erythematous papules and few linear burrows concentrated in the interdigital spaces.

Chancroid, with characteristic painful penile ulcers and associated left inguinal adenitis (bubo).

Condylomata acuminata are lesions induced by human papillomavirus and in this patient are seen as multiple verrucous papules coalescing into plaques. (Courtesy of S. Wright Caughman, MD; with permission.)

A patient with features of polar lepromatous leprosy: multiple nodular skin lesions, particularly of the forehead, and loss of eyebrows. (Courtesy of Robert Gelber, MD; with permission.)

Skin lesions of neutropenic patients. A. Hemorrhagic papules on the foot of a patient undergoing treatment for multiple myeloma. Biopsy and culture demonstrated Aspergillosis species. B. Eroded nodule on the hard palate of a patient undergoing chemotherapy. Biopsy and culture demonstrated Mucor species. C. Ecthyma gangrenosum in a neutropenic patient with Pseudomonas aeruginosa bacteremia.

Septic emboli, with hemorrhage and infarction due to acute Staphylococcus aureus endocarditis. (Courtesy of L. Baden, MD; with permission.)

Vegetations (arrows) due to viridans streptococcal endocarditis involving the mitral valve. (Courtesy of AW Karchmer, MD; with permission.)

Disseminated gonococcemia in the skin is seen as hemorrhagic papules and pustules with purpuric centers in an acral distribution. (Courtesy of Daniel M. Musher, MD; with permission.)

Lupus erythematosus. A. Systemic lupus erythematosus, with prominent, scaly malar erythema. Involvement of other sun-exposed sites is also common. B. Acute lupus erythematosus on the upper chest, with brightly erythematous and slightly edematous coalescence of papules and plaques. (B: Courtesy of Robert Swerlick, MD; with permission.)

Discoid lupus erythematosus. Atrophic, hypopigmented plaques and patches surrounded by hyperpigmentation and erythema in association with scarring and alopecia are characteristic of this cutaneous form of lupus.

Dermatomyositis. Periorbital violaceous erythema characterizes the classic heliotrope rash. (Courtesy of James Krell, MD; with permission.)

Scleroderma characterized by typical expressionless, mask-like facies.

Dermatomyositis often involves the hands as erythematous flat-topped papules over the knuckles (Gottron’s papules) and periungual telangiectases.

Scleroderma, with acral sclerosis and focal digital ulcers.

Erythema multiforme is characterized by multiple erythematous plaques with a target or iris morphology and usually represents a hypersensitivity reaction to drugs or infections (especially herpes simplex virus). (Courtesy of Yale Resident’s Slide Collection; with permission.)

Dermatitis herpetiformis, manifested by pruritic, grouped vesicles in a typical location. The vesicles are often excoriated and may also occur on the knees, buttocks, elbows, and posterior scalp.

Pemphigus vulgaris. A. Eroded bullae on the back. B. The oral mucosa is almost invariably involved, sometimes with erosions on the gingiva, buccal mucosa, palate, posterior pharynx, or tongue. (B: Courtesy of Robert Swerlick, MD; with permission.)

Erythema nodosum is a panniculitis characterized by tender deep-seated nodules and plaques, usually located on the lower extremities. (Courtesy of Robert Swerlick, MD; with permission.)

Vasculitis. Palpable purpuric papules on the lower legs are seen in this patient with cutaneous small-vessel vasculitis. (Courtesy of Robert Swerlick, MD; with permission.)

Bullous pemphigoid, with tense vesicles and bullae on an erythematous, urticarial base. (Courtesy of Yale Resident’s Slide Collection; with permission.)

Acanthosis nigricans, with typical hyperpigmented plaques on a velvet-like, verrucous surface on the neck.

Pretibial myxedema manifesting as waxy, infiltrated plaques in a patient with Graves’ disease.

Erythematous, indurated plaque of Sweet syndrome, with a pseudovesicular border. (Courtesy of Robert Swerlick, MD, with permission.)

Bilateral rheumatoid nodules of the upper extremities. (Courtesy of Robert Swerlick, MD; with permission.)

Neurofibromatosis, with numerous flesh-colored cutaneous neurofibromas.

Coumarin necrosis. Shown is cutaneous and subcutaneous necrosis of a breast. Other fatty areas, such as buttocks and thighs, are also common sites of involvement. (Courtesy of Kim Yancey, MD; with permission.)

Sarcoid. A. Infiltrated papules and plaques of variable color are seen in a typical paranasal and periorbital location. B. Infiltrated, hyperpigmented, and slightly erythematous coalescent papules and plaques on the upper arm. (B: Courtesy of Robert Swerlick, MD; with permission.)

Pyoderma gangrenosum on the dorsal aspect of both hands. Multiple necrotic ulcers are surrounded by a violaceous and undermined border. (Courtesy of Robert Swerlick, MD; with permission.)