Fitzgerald4982_Ch04 Fitzgerald4982_Ch04
Skin Disorders
Skin Lesions ■ Where is the oldest lesion, and when did it occur? Where is
the newest lesion, and when did it occur?
4
■ This allows the examiner to assess the evolution of the
Identification of common dermatological lesions is impor-
tant to safe clinical practice. To succeed in practice, the cli- skin lesions.
■ Is the person otherwise well?
nician must speak “the language of dermatology.” Doing so
■ If otherwise well, the person likely has a condition lim-
requires learning key clinical concepts in dermatology and
being able to define key terms (Table 4-1). ited to the skin, such as rosacea or keratosis pilaris.
■ Is the person highly symptomatic but not systemically ill?
■ Primary skin lesions: These are skin lesions that have ■ Often, the person with a skin condition is generally well
resulted from a disease process and have not been altered but is highly symptomatic with itch, pain, or other com-
by outside manipulation, treatment, or the natural course plaint, such as eczema (itch) or zoster (pain and itch).
of disease. ■ Is the person systemically ill?
■ Example of a primary skin lesion: Vesicle, a fluid-filled
■ The person who is systemically ill with fever, involun-
lesion, diameter less than 1 cm, noted in varicella (chick- tary weight loss, fatigue, and a dermatological condition
enpox), herpes zoster (shingles), and herpes simplex often has a serious condition with a dermatological man-
type 1 and type 2. ifestation, such as systemic lupus erythematosus (SLE) or
■ Secondary skin lesions: These are skin lesions altered by
Lyme disease.
outside manipulation, treatment, and/or the natural course ■ What type of lesion or lesions are noted?
of disease. ■ What is the pattern of the lesions?
■ Example of a secondary skin lesion: Crust, a raised lesion
■ Identifying the type of lesion(s) and lesion pattern is crit-
caused by dried serum and blood remnants, develops ical to arriving at the correct diagnosis.
when a vesicle ruptures.
Discussion Sources
In addition, see the following key assessment tips in car-
Ball, J. W., Dains, J. E., Flynn, J. A., et al. (2023). Seidel’s guide to physical
ing for the person who presents with a dermatology prob- examination (10th ed.). Mosby.
lem. In addition to the typical history of present illness and Goolsby, M., & Grubbs, L. (2023). Advanced assessment: Interpreting find-
symptom analysis, ask the following questions: ings and formulating differential diagnoses (5th ed.). F.A. Davis.
79
Page 1 Fitzgerald4982_Ch04.pdf
,Fitzgerald4982_Ch04 Fitzgerald4982_Ch04
80 CHAPTER FOUR ■ Skin Disorders
TA BLE 4-1 Skin Lesions
LESION DESCRIPTION EXAMPLE
Common Primary Skin Lesions
Macule Flat discoloration, usually less than 1 cm in diameter Freckle
Patch Flat area of skin discoloration, larger than a macule Vitiligo
Papule Raised lesion, less than 1 cm, may be the same or Raised nevus
different color than the surrounding skin
Vesicle Fluid filled, less than 1 cm Varicella
Plaque Raised lesion, ≥1 cm, may be the same or different Psoriasis
color than surrounding skin
Purpura Lesions caused by red blood cells leaving circulation Petechiae, ecchymosis
and becoming trapped in skin
Pustule Vesicle-like lesion with purulent content Impetigo, acne
Wheal Circumscribed area of skin edema Hive
Nodule Raised lesion, ≥1 cm, usually mobile Epidermal cyst
Bulla Fluid filled, ≥1 cm Blister with second-degree burn
Common Secondary Skin Lesions
Excoriation Marks produced by scratching Seen in areas of pruritic skin diseases
Lichenification Skin thickening resembling callus formation Seen in areas of recurrent scratching
Fissure Narrow linear crack into epidermis, exposing dermis Split lip, athlete’s foot
Erosion Partial focal loss of epidermis; heals without scarring Area exposed after bullous lesion opens
Ulcer Loss of epidermis and dermis; heals with scarring Pressure sore
Scale Raised, flaking lesion Dandruff, psoriasis
Atrophy Loss of skin markings and full skin thickness Area treated excessively with higher-
potency corticosteroids
Terms Describing Patterns of Skin Lesions
Annular In a ring Erythema migrans in Lyme disease
Confluent or coalescent Multiple lesions blending together Multiple skin conditions
Reticular Net-like cluster Multiple skin conditions
Dermatomal Along a neurocutaneous dermatome Herpes zoster
Linear In streaks Poison ivy
Source: Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2023). Seidel’s guide to physical examination (10th ed.). Mosby.
QUESTIONS
1 to 10. Match the following descriptions to the correct lesion names.
1. Fluid-filled lesion of less than 1 cm in diameter
2. Flat discoloration less than 1 cm in diameter
3. Circumscribed area of skin edema
4. Narrow linear crack into epidermis, exposing dermis
Page 2 Fitzgerald4982_Ch04.pdf
,Fitzgerald4982_Ch04 Fitzgerald4982_Ch04
Skin Disorders ■ CHAPTER FOUR 81
5. Vesicle-like lesion with purulent content
6. Flat discoloration greater than 1 cm in diameter
7. Raised lesion, larger than 1 cm, may be the same or a different color from the surrounding
skin
8. Loss of epidermis and dermis
9. Loss of skin markings and full skin thickness
10. Skin thickening usually found over pruritic or friction areas
A. ulcer
B. atrophy
C. fissure
D. wheal
E. pustule
F. patch
G. plaque
H. macule
I. vesicle
J. lichenification
11 to 15. Match the following descriptions with the correct distribution name.
11. Multiple lesions blending together
12. Net-like cluster
13. In a ring formation
14. In streaks
15. Along a neurocutaneous dermatome
A. reticular
B. linear
C. annular
D. confluent or coalescent
E. dermatomal
16 to 17. Match the type of skin lesion with the correct definition.
16. Primary
17. Secondary
A. resulting from a disease process and unaltered by outside manipulation, treatment, or the
natural course of disease
B. altered by outside manipulation, treatment, and/or the natural course of disease
For answers and rationales, see end of chapter.
Dermatology Pharmacology
T OPICAL M EDICATION D ISPENSING
Knowledge of the amount of a cream or ointment needed to treat a dermatological condition with a topical
medication is an important part of the prescriptive practice (Table 4-2).
Aside from providers not prescribing a sufficient amount of medication, patients often are confused
as to how much of the cream or ointment to apply. A helpful way of teaching a patient the appropriate
amount of a cream or ointment to apply on a problematic area of skin is to use the “fingertip unit” (FTU)
method of measurement. One FTU is the amount of topical cream or ointment that is squeezed out from a
Page 3 Fitzgerald4982_Ch04.pdf
, Fitzgerald4982_Ch04 Fitzgerald4982_Ch04
82 CHAPTER FOUR ■ Skin Disorders
TA BL E 4 -2 Topical Medication-Dispensing Formulas
AMOUNT NEEDED AMOUNT NEEDED
AMOUNT NEEDED IN TWICE-A-DAY IN TWICE-A-DAY
FOR ONE APPLICATION FOR APPLICATION FOR
APPLICATION 1 WEEK 1 MONTH
Hands, head, face, 2g 28 g 120 g (4 oz)
anogenital region
One arm, anterior or 3g 42 g 180 g (6 oz)
posterior trunk
One leg 6g 84 g 320 g (12 oz)
Entire body 30–60 g 420–840 g (14–28 oz) 1.8–3.6 kg (60–120 oz
or 3.75–7.5 lbs)
Source: Amerson, E. H., Burgin, S., & Shinkai, K. (2019). Fundamentals of clinical dermatology: Morphology and special clinical considerations. In S. Kang,
M. Amagai, A. L. Bruckner, A. H. Enk, D. J. Margolis, A. J. McMichael, & J. S. Orringer (Eds.), Fitzpatrick’s dermatology (9th ed.). McGraw Hill.
standard tube along an adult’s fingertip. A fingertip is from the very end of the finger
to the first crease in the finger. Two FTUs is approximately 1 gram of a topical cream
CLINICAL CONCEPT
or ointment.
Clinicians often write pre- One FTU of a cream or ointment is enough to treat an area of skin twice the size of
scriptions for an inadequate the palm of an adult’s hand with the fingers together, or approximately 2% total body
amount of a topical medi- surface area (TBSA) for the average adult.
cation with an insufficient
number of refills, possibly Discussion Sources
Amerson, E. H., Burgin, S., & Shinkai, K. (2019). Fundamentals of clinical dermatology: Morphology and
creating a situation in which special clinical considerations. In S. Kang, M. Amagai, A. L. Bruckner, A. H. Enk, D. J. Margolis, A. J.
treatment fails because of an McMichael, & J. S. Orringer (Eds.), Fitzpatrick’s dermatology (9th ed.). McGraw Hill.
inadequate length of therapy. Ball, J. W., Dains, J. E., Flynn, J. A., et al. (2023). Seidel’s guide to physical examination (10th ed.). Mosby.
National Eczema Association. (2023). Fingertip units for topical steroids. https://patient.info/treatment
-medication/steroids/fingertip-units-for-topical-steroids
QUESTIONS
18. How many grams of a topical cream or ointment are needed for a single application to the hands?
A. 1
B. 2
C. 3
D. 4
19. How many grams of a topical cream or ointment are needed for a single application to the entire
body?
A. 10 to 30
B. 30 to 60
C. 60 to 90
D. 90 to 120
20. How many grams of a topical cream or ointment can be expected in two FTUs?
A. 1
B. 3
C. 5
D. 10
For answers and rationales, see end of chapter.
Page 4 Fitzgerald4982_Ch04.pdf
Skin Disorders
Skin Lesions ■ Where is the oldest lesion, and when did it occur? Where is
the newest lesion, and when did it occur?
4
■ This allows the examiner to assess the evolution of the
Identification of common dermatological lesions is impor-
tant to safe clinical practice. To succeed in practice, the cli- skin lesions.
■ Is the person otherwise well?
nician must speak “the language of dermatology.” Doing so
■ If otherwise well, the person likely has a condition lim-
requires learning key clinical concepts in dermatology and
being able to define key terms (Table 4-1). ited to the skin, such as rosacea or keratosis pilaris.
■ Is the person highly symptomatic but not systemically ill?
■ Primary skin lesions: These are skin lesions that have ■ Often, the person with a skin condition is generally well
resulted from a disease process and have not been altered but is highly symptomatic with itch, pain, or other com-
by outside manipulation, treatment, or the natural course plaint, such as eczema (itch) or zoster (pain and itch).
of disease. ■ Is the person systemically ill?
■ Example of a primary skin lesion: Vesicle, a fluid-filled
■ The person who is systemically ill with fever, involun-
lesion, diameter less than 1 cm, noted in varicella (chick- tary weight loss, fatigue, and a dermatological condition
enpox), herpes zoster (shingles), and herpes simplex often has a serious condition with a dermatological man-
type 1 and type 2. ifestation, such as systemic lupus erythematosus (SLE) or
■ Secondary skin lesions: These are skin lesions altered by
Lyme disease.
outside manipulation, treatment, and/or the natural course ■ What type of lesion or lesions are noted?
of disease. ■ What is the pattern of the lesions?
■ Example of a secondary skin lesion: Crust, a raised lesion
■ Identifying the type of lesion(s) and lesion pattern is crit-
caused by dried serum and blood remnants, develops ical to arriving at the correct diagnosis.
when a vesicle ruptures.
Discussion Sources
In addition, see the following key assessment tips in car-
Ball, J. W., Dains, J. E., Flynn, J. A., et al. (2023). Seidel’s guide to physical
ing for the person who presents with a dermatology prob- examination (10th ed.). Mosby.
lem. In addition to the typical history of present illness and Goolsby, M., & Grubbs, L. (2023). Advanced assessment: Interpreting find-
symptom analysis, ask the following questions: ings and formulating differential diagnoses (5th ed.). F.A. Davis.
79
Page 1 Fitzgerald4982_Ch04.pdf
,Fitzgerald4982_Ch04 Fitzgerald4982_Ch04
80 CHAPTER FOUR ■ Skin Disorders
TA BLE 4-1 Skin Lesions
LESION DESCRIPTION EXAMPLE
Common Primary Skin Lesions
Macule Flat discoloration, usually less than 1 cm in diameter Freckle
Patch Flat area of skin discoloration, larger than a macule Vitiligo
Papule Raised lesion, less than 1 cm, may be the same or Raised nevus
different color than the surrounding skin
Vesicle Fluid filled, less than 1 cm Varicella
Plaque Raised lesion, ≥1 cm, may be the same or different Psoriasis
color than surrounding skin
Purpura Lesions caused by red blood cells leaving circulation Petechiae, ecchymosis
and becoming trapped in skin
Pustule Vesicle-like lesion with purulent content Impetigo, acne
Wheal Circumscribed area of skin edema Hive
Nodule Raised lesion, ≥1 cm, usually mobile Epidermal cyst
Bulla Fluid filled, ≥1 cm Blister with second-degree burn
Common Secondary Skin Lesions
Excoriation Marks produced by scratching Seen in areas of pruritic skin diseases
Lichenification Skin thickening resembling callus formation Seen in areas of recurrent scratching
Fissure Narrow linear crack into epidermis, exposing dermis Split lip, athlete’s foot
Erosion Partial focal loss of epidermis; heals without scarring Area exposed after bullous lesion opens
Ulcer Loss of epidermis and dermis; heals with scarring Pressure sore
Scale Raised, flaking lesion Dandruff, psoriasis
Atrophy Loss of skin markings and full skin thickness Area treated excessively with higher-
potency corticosteroids
Terms Describing Patterns of Skin Lesions
Annular In a ring Erythema migrans in Lyme disease
Confluent or coalescent Multiple lesions blending together Multiple skin conditions
Reticular Net-like cluster Multiple skin conditions
Dermatomal Along a neurocutaneous dermatome Herpes zoster
Linear In streaks Poison ivy
Source: Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2023). Seidel’s guide to physical examination (10th ed.). Mosby.
QUESTIONS
1 to 10. Match the following descriptions to the correct lesion names.
1. Fluid-filled lesion of less than 1 cm in diameter
2. Flat discoloration less than 1 cm in diameter
3. Circumscribed area of skin edema
4. Narrow linear crack into epidermis, exposing dermis
Page 2 Fitzgerald4982_Ch04.pdf
,Fitzgerald4982_Ch04 Fitzgerald4982_Ch04
Skin Disorders ■ CHAPTER FOUR 81
5. Vesicle-like lesion with purulent content
6. Flat discoloration greater than 1 cm in diameter
7. Raised lesion, larger than 1 cm, may be the same or a different color from the surrounding
skin
8. Loss of epidermis and dermis
9. Loss of skin markings and full skin thickness
10. Skin thickening usually found over pruritic or friction areas
A. ulcer
B. atrophy
C. fissure
D. wheal
E. pustule
F. patch
G. plaque
H. macule
I. vesicle
J. lichenification
11 to 15. Match the following descriptions with the correct distribution name.
11. Multiple lesions blending together
12. Net-like cluster
13. In a ring formation
14. In streaks
15. Along a neurocutaneous dermatome
A. reticular
B. linear
C. annular
D. confluent or coalescent
E. dermatomal
16 to 17. Match the type of skin lesion with the correct definition.
16. Primary
17. Secondary
A. resulting from a disease process and unaltered by outside manipulation, treatment, or the
natural course of disease
B. altered by outside manipulation, treatment, and/or the natural course of disease
For answers and rationales, see end of chapter.
Dermatology Pharmacology
T OPICAL M EDICATION D ISPENSING
Knowledge of the amount of a cream or ointment needed to treat a dermatological condition with a topical
medication is an important part of the prescriptive practice (Table 4-2).
Aside from providers not prescribing a sufficient amount of medication, patients often are confused
as to how much of the cream or ointment to apply. A helpful way of teaching a patient the appropriate
amount of a cream or ointment to apply on a problematic area of skin is to use the “fingertip unit” (FTU)
method of measurement. One FTU is the amount of topical cream or ointment that is squeezed out from a
Page 3 Fitzgerald4982_Ch04.pdf
, Fitzgerald4982_Ch04 Fitzgerald4982_Ch04
82 CHAPTER FOUR ■ Skin Disorders
TA BL E 4 -2 Topical Medication-Dispensing Formulas
AMOUNT NEEDED AMOUNT NEEDED
AMOUNT NEEDED IN TWICE-A-DAY IN TWICE-A-DAY
FOR ONE APPLICATION FOR APPLICATION FOR
APPLICATION 1 WEEK 1 MONTH
Hands, head, face, 2g 28 g 120 g (4 oz)
anogenital region
One arm, anterior or 3g 42 g 180 g (6 oz)
posterior trunk
One leg 6g 84 g 320 g (12 oz)
Entire body 30–60 g 420–840 g (14–28 oz) 1.8–3.6 kg (60–120 oz
or 3.75–7.5 lbs)
Source: Amerson, E. H., Burgin, S., & Shinkai, K. (2019). Fundamentals of clinical dermatology: Morphology and special clinical considerations. In S. Kang,
M. Amagai, A. L. Bruckner, A. H. Enk, D. J. Margolis, A. J. McMichael, & J. S. Orringer (Eds.), Fitzpatrick’s dermatology (9th ed.). McGraw Hill.
standard tube along an adult’s fingertip. A fingertip is from the very end of the finger
to the first crease in the finger. Two FTUs is approximately 1 gram of a topical cream
CLINICAL CONCEPT
or ointment.
Clinicians often write pre- One FTU of a cream or ointment is enough to treat an area of skin twice the size of
scriptions for an inadequate the palm of an adult’s hand with the fingers together, or approximately 2% total body
amount of a topical medi- surface area (TBSA) for the average adult.
cation with an insufficient
number of refills, possibly Discussion Sources
Amerson, E. H., Burgin, S., & Shinkai, K. (2019). Fundamentals of clinical dermatology: Morphology and
creating a situation in which special clinical considerations. In S. Kang, M. Amagai, A. L. Bruckner, A. H. Enk, D. J. Margolis, A. J.
treatment fails because of an McMichael, & J. S. Orringer (Eds.), Fitzpatrick’s dermatology (9th ed.). McGraw Hill.
inadequate length of therapy. Ball, J. W., Dains, J. E., Flynn, J. A., et al. (2023). Seidel’s guide to physical examination (10th ed.). Mosby.
National Eczema Association. (2023). Fingertip units for topical steroids. https://patient.info/treatment
-medication/steroids/fingertip-units-for-topical-steroids
QUESTIONS
18. How many grams of a topical cream or ointment are needed for a single application to the hands?
A. 1
B. 2
C. 3
D. 4
19. How many grams of a topical cream or ointment are needed for a single application to the entire
body?
A. 10 to 30
B. 30 to 60
C. 60 to 90
D. 90 to 120
20. How many grams of a topical cream or ointment can be expected in two FTUs?
A. 1
B. 3
C. 5
D. 10
For answers and rationales, see end of chapter.
Page 4 Fitzgerald4982_Ch04.pdf
