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Morphology:How to describe what you seeMedical Student Core Curriculum in Dermatology

Last updated June 13, 20111Module InstructionsThe following module contains a number of blue, underlined terms which are hyperlinked to the dermatology glossary, an illustrated interactive guide to clinical dermatology and dermatopathology.We encourage the learner to read all the hyperlinked information.2Goals and ObjectivesThe purpose of this module is to help medical students learn how to best describe skin lesionsAfter completing this module, the learner will be able to:Develop a systematic approach to describing skin eruptionsUtilize the descriptors and definitions of morphology 3MorphologyThe word morphology is used by dermatologists to describe the use of descriptors to accurately characterize and document skin lesionsThe morphologic characteristics of skin lesions are key elements in establishing the diagnosis and communicating skin findingsThere are two steps in establishing the morphology of any given skin condition:Careful visual inspectionApplication of correct descriptors4Visual InspectionVisual inspection at its core is much like analyzing a painting or looking at any object for the first time.

Question 1How would you fill in the description of the item depicted on the next slide?5Question 1This is a _____ _______ _____ object measuring ____ with ___ ____ in the center. It is sitting on a ____ __________ and casts a ______.

6Question 1This is a brown circular shiny object measuring 8 mm with four holes in the center. It is sitting on a blue background and casts a shadow. The shadow tells us it is raised (palpable).

7Question 1This is a brown circular shiny object measuring 8 mm with four holes in the center. It is sitting on a blue background and casts a shadow.The above description identifies:Palpability (indicated by shadow)ColorShapeTextureSizeLocation

8We will use the same principles to learn the vocabulary of the skin (i.e. morphology)9Case OneMr. F10Case One: HistoryHPI: Mr. F is a 32-year-old man who presents to his primary care provider with blotches on his upper back, chest, and arms for several years. They are more noticeable in the summertime.PMH: shoulder pain from an old sports injuryAllergies: noneMedications: NSAID as neededFamily history: not contributorySocial history: auto mechanicROS: negative11Case One: Skin Exam

12Case OneHow would you describe this skin exam to a resident or an attending?What do you see? Look carefully at all clues in the photographs.There are many right ways to describe something. Be creative.13Case One, Question 1 Are these lesions raised, flat, or depressed?

14Case One, Question 1 Imagine running your finger over them. Close your eyes when you do so.You dont feel anything as your finger runs across themThey are flatSmall, flat lesions are called macules

15Case One, Question 2 How else can you describe them?What size are they?What shape are they?What color are they?How regular and distinct is the border?How are they configured?How are they distributed?

16Case One, Question 2 How else can you describe them?3 to 10 mm

17Case One, Question 3 How else can you describe them?What size are they?What shape are they?What color are they?How regular and distinct is the border?How are they configured?How are they distributed?

18Case One, Question 3 How else can you describe them?3 to 10 mmRound to oval

19Case One, Question 4 How else can you describe them?What size are they?What shape are they?What color are they?How regular and distinct is the border?How are they configured?How are they distributed?

20Case One, Question 4 How else can you describe them?3 to 10 mmRound to ovalPink to tan

21Case One, Question 5 How else can you describe them?What size are they?What shape are they?What color are they?How regular and distinct is the border?How are they configured?How are they distributed?

22Case One, Question 5 How else can you describe them?3 to 10 mmRound to ovalPink to tanSharp, irregular borders

23Case One, Question 6 How else can you describe them?What size are they?What shape are they?What color are they?How distinct are they?How are they configured (how do the lesions relate to each other)?How are they distributed (where are they on the body)?

24Case One, Question 6 How else can you describe them?3 to 10 mmRound to ovalPink to tanSharp, irregular bordersSeparate, in no particular pattern

25Case One, Question 7 How else can you describe them?What size are they?What shape are they?What color are they?How distinct are they?How are they configured?How are they distributed?

26Case One, Question 7 How else can you describe them?3 to 10 mmRound to ovalPink to tanSharp, irregular bordersSeparate, in no particular patternOn the upper chest and back, and flexures of arms

27Skin ExamMr. Fs skin exam shows:Multiple 3 to 10 mm pink to tan-colored, round, flat lesions with sharp, irregular borders and varying sizes on his upper chest, back and flexures of the arms. Small (< 1cm) flat lesions are called maculesIn this case, the primary lesion is a macule

28DiagnosisDr. D performs a potassium hydroxide exam and based on the findings, diagnoses Mr. F with tinea versicolor. The primary lesion in tinea versicolor is a macule.

29Describing lesions: MorphologyDermatologys short-hand vocabulary is called morphologyThis allows medical personnel to communicate skin findings succinctlyDermatologists attempt to identify the primary lesion of any skin eruptionPrimary lesions are the nouns that other adjectives modify30MorphologyAs you go through the following cases, you will learn the vocabulary of primary lesionsWhat matters most is that your description captures the essence of the lesion, even if you do not use classic morphological words

31Primary lesion: Macule(L. macula, spot)A macule is flat; if you can feel it, then its not a macule.Usually caused by color changes in the epidermis or upper dermis

32Examples of Macules

33Case One, Question 8Macules can:Feel raisedFeel flatContain fluidBe any shape34Case One, Question 8Answer: b & dMacules can:Feel raised (these are papules or plaques)Feel flatContain fluid (these are vesicles or bullae)Be any shape35MaculesPresence of a macule indicates that the process is confined to the epidermisMacules do not contain fluid and are not raisedMacules can have secondary changes such as scale or crustIf a flat lesion is over 1 cm it is called a patch36Primary lesion: PatchPatches are flat but larger than maculesIf its flat and larger than 1 cm, call it a patch

37Examples of Patches

38Macule and Patch

MACULE (1cm)39Case TwoMr. K40Case Two: HistoryHPI: Mr. K is a 36-year-old man who presents with four years of itchy, flaky spots on his elbows, knees, and lower back. They have not improved with moisturizers.PMH: noneAllergies: noneMedications: noneFamily history: father died from heart attack at age 68Social history: delivery truck driverHealth-related behaviors: drinks 2-3 beers a weekROS: negative41Case Two: Skin Exam

42Case TwoHow would you describe this skin exam to a resident or an attending?What do you see when you look at these photographs? 43Case Two, Question 1 Are these lesions raised, flat, or depressed?

44Case Two, Question 1 Imagine running your finger over them. Close your eyes.These are raisedLarge (>1cm), plateau-like, raised lesions are called plaques

45Case Two How else can you describe them?Size?Shape?Color?Sharp borders?Texture?Configuration?Distribution?

46Case Two How else can you describe them?3 to 10 cmRound to geographic (like outlines on a map)PinkSharply circumscribedScalySymmetricalExtensor surfaces (knees, elbows), back, gluteal cleft

47Describing colorDescribing colors of lesions is challengingBe creative. Learn lots of colors. There are infinite shades of skin tonesSkin-colored refers to a lesion the same color as the patients skin toneLearn the classic color assigned to skin conditions as you read about them48Skin ExamMr. Ks skin exam shows:Several 3-10 cm bright pink round sharply circumscribed scaly plaques on extensor elbows, knees, lower back, and gluteal cleftLarge, raised lesions are called plaquesMr. K has psoriasis. The primary lesion in psoriasis is a plaque.

49Primary lesions: Plaque

Plaques are raised lesions larger than 1 cmYou can feel themCast a shadow with side lightingA proliferation of cells in epidermis or superficial dermis

50Examples of Plaques

51Raised lesionsA raised lesion measuring less than 1 cm is called a ______.52Raised lesionsA raised lesion measuring less than 1 cm is called a papule.53Primary lesion: Papule(L. papula, pimple)Papules are raised lesions less than 1 cmA proliferation of cells in epidermis or superficial dermis

54Examples of Papules

55Papule and PlaquePAPULE (1cm)

56A larger, deep papule is called a57Nodule(L. nodulus, small knot)A proliferation of cells down to the mid-dermis

58Nodule

A raised area in the skin where the overlying epidermis looks and feels normal, but there is a proliferation of cells in deeper tissues is called a nodule.59Case ThreeMr. B60Case ThreeHPI: Mr. B is a 28-year-old man who presents with four days of pain and blisters on his left chest.PMH: noneAllergies: noneMedications: noneFamily history: noncontributorySocial history: single; works as a personal trainerROS: negative61Case Three

62Case ThreeHow would you describe this skin exam to a resident or an attending?What do you see when you look at these photographs? 63Case Three, Questions Are these lesions raised, flat, or depressed?Do they have fluid in them?

64Case Three, Questions Imagine running your finger over them. These are raisedThey do have fluid in themSmall, raised, fluid-filled lesions are called vesicles65

Case Three How else can you describe them?Size?Shape?Color?Texture?Configuration?Distribution?66

Case Three How else can you describe them?2 5 mmRound to ovalClear, with red backgroundFluid-filledGrouped, dermatomal configurationUnilateral left chest67

Distribution / ConfigurationPart of describing lesions is noting distribution and configurationDistribution means location on the bodyConfiguration means how the lesions are arranged or relate to each other

Lesions are grouped but also follow a linear pattern around the trunkThis is an example of a linear or dermatomal configuration68Distribution / ConfigurationTo learn more about distributions, click here:http://bit.ly/itkitkTo learn more about configurations, click here:http://bit.ly/kbRI9Q69Skin ExamMr. Bs skin exam shows:Grouped 2-5 mm vesicles on an erythematous base in a unilateral, dermatomal configuration on the left chestSmall, fluid-filled lesions are called vesiclesMr. K has shingles. The primary lesion in shingles is a vesicle.

70Primary lesion: Vesicle(L. vesicula, little bladder; bulla, bubble)Vesicles are fluid-filled papules (small blisters)A large (> 1cm) blister is called a bulla

vesiclebulla71Examples of Vesicles

72A vesicle filled with pus is called a73PustulePus is made up of leukocytes and a thin fluid called liquor puris (L. pus liquid)See also furuncle and abscess

74A superficial loss of the epidermis is called an75ErosionErosions are loss of the epidermisThey may occur after a vesicle forms and the top peels offThey weep and become crustedThis is an example of a secondary change or characteristic

76If an erosion involves the dermis, it is called an77Ulcer(L. ulcus, sore)Ulcers often heal with scarring; erosions usually do notErosions and ulcers are secondary lesionsSecondary lesions (or changes) may evolve from primary lesions, or may be caused by external forces such as scratching, trauma, infection, or the healing process

78Seeing the skinTo describe what you see on the skin, first determine the primary lesionIs it raised, flat, or depressed?Is it small or large?Is it fluid-filled?The table in the next slide summarizes most of the primary lesions and common secondary lesions. We have already reviewed many of them. Click on the others to learn more.79Primary and Secondary LesionsRaisedFlatDepressedFluid-filledVascularPapuleMaculeErosionVesicleTelangiectasiaPlaquePatchUlcerBullaPetechiaeNoduleAtrophyPustuleEcchymosisTumorSinusFuruncleWhealStriaAbscessBurrowScar80Seeing the skinIn your descriptions, include adjectives that help describe the primary lesionsSize Shape Its okay to say small, raised lesion, but papule is more concise.It is more important to describe what you see, than to state what you think the diagnosis is

Color Texture ConfigurationDistribution 81This is an 8mm brown circular shiny raised object with four holes in the center. After reading the description, without seeing the image, you could visualize a button in your mind. Someone who reads your note could make the diagnosis of a buttonDescribe skin lesions this way in your notes and consults

Seeing the skin82Take Home PointsTo describe the skin, you first have to see itBe creative in your descriptions, especially subjective things like color. First, determine whether lesions are raised, flat, or depressed. Use this with size to determine the primary lesion.The primary lesion is the noun that you describe with adjectives like exact size, shape, color, texture, distribution, and configuration.83AcknowledgementsThis module was developed by the American Academy of Dermatologys Medical Student Core Curriculum Workgroup from 2008-2012.Primary authors: Patrick McCleskey, MD, FAAD; Peter A. Lio, MD, FAAD; Jacqueline C. Dolev, MD, FAAD; Amit Garg, MD, FAAD.Peer reviewers: Heather Woodworth Wickless, MD, MPH; Ron Birnbaum, MD; Timothy G. Berger, MD, FAAD.Revisions: Sarah D. Cipriano, MD, MPH. Last revised June 2011.84ReferencesBerger T, Hong J, Saeed S, Colaco S, Tsang M, Kasper R. The Web-Based Illustrated Clinical Dermatology Glossary. MedEdPORTAL; 2007. Available from: www.mededportal.org/publication/462.Morphology illustrations are from the Dermatology Lexicon Project, which is now maintained by the American Academy of Dermatology as DermLex.Dolev JC, Friedlaender JK, Braverman, IM. Use of fine art to enhance visual diagnostic skills. JAMA 2001; 286(9), 100-2.Habif TP. Clinical Dermatology: a color guide to diagnosis and therapy, 4th ed. New York, NY: Mosby; 2004.Marks Jr JG, Miller JJ. Lookingbill and Marks Principles of Dermatology, 4th ed. Elsevier; 2006. Review primary lesions and other morphologic terms at http://www.logicalimages.com/educationalTools/learnDerm.htm.85