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Dermatology for Internists. Susan Riggs Runge, MD January 2008. Pictures. Pictures of common and less common skin lesions Cover each topic very briefly Realize most of you have vast experience in seeing many of these lesions in your years of practice

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Dermatology for Internists

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Dermatology for internists

Dermatology for Internists

Susan Riggs Runge, MD

January 2008



  • Pictures of common and less common skin lesions

  • Cover each topic very briefly

  • Realize most of you have vast experience in seeing many of these lesions in your years of practice

  • This is a very superficial review of topics I hope you may find interesting

  • All slides and photos are available at:

Lupus erythematosus

Lupus Erythematosus

  • One of the papulosquamous diseases

  • Papules and scaly areas

  • Other papulosquamous diseases include: psoriasis, tinea, seborrheic dermatitis, pityriasis rosea, syphilis, lichen planus and other more rare skin disorders

  • Many of these have differentiating characteristics but lots of overlap clinically makes skin biopsy particularly helpful in many cases

Acute cutaneous lupus

Acute Cutaneous Lupus

Acute cutaneous lupus1

Dilated capillary loops along nail fold

This can also be seen in dermatomyositis and other connective tissue diseases

Acute Cutaneous Lupus

Acute cutaneous lupus2

Malar erythema, can involve neck, forehead and periorbital area in photodistribution

Erythema and sometimes edema of V of neck, forearms

Look for ulcers on the hard palate

ANA positive

60-80% will have positive dsDNA

Other tests: CBC, ESR, UA, skin biopsy

Treatments: Prednisone, hydroxychloroquine

Referral to rheumatologist

Acute Cutaneous Lupus

Subacute cutaneous lupus

Subacute Cutaneous Lupus

Scle subacute cutaneous lupus

Annular scaly erythematous patches in sun-exposed areas

Worse upon sun exposure


Many patients have arthralgias expecially of hands and wrists

Consider drugs as cause: HCTZ, calcium channel blockers, ACE inhibitors, terbinafine and TNF-antagonists

SCLE (subacute cutaneous lupus)

Hands in subacute cutaneous lupus

Erythematous scaly patches between the knuckles (unlike Gottron’s papules of dermatomyositis which are on the knuckles)

Hands in Subacute Cutaneous Lupus

Subacute cutaneous lupus labs

Most are ANA positive

Most are Anti-Ro (SS-A) positive

1/3 will meet criteria for systemic lupus

Other lab tests: CBC, ESR, UA, Rheumatoid factor, complement levels, skin biopsy

Treatment: Stop suspected drugs, sunscreen, hydroxychloroquine

Refer to rheumatologist if joint involvement, nephrologist if renal involvement, etc

Subacute Cutaneous Lupus Labs

Subacute cutaneous lupus more subtle

Subacute Cutaneous Lupus-more subtle

Discoid lupus

Discoid Lupus

Discoid lupus1

Hyperpigmentation and hypopigmentation

Atrophy of skin

These lesions cause SCARRING

Skin lesions occur in photodistributed areas (wider distribution may correlate with greater likelihood of SLE)

Discoid lesions and follicular prominence in conchae of ears

Discoid lupus

Ear lesions in discoid lupus

Ear Lesions in Discoid Lupus

Discoid lupus labs

ANA positive in 5-20%

Do CBC, ESR, Rheumatoid factor, UA, complement levels, skin biopsy

Discoid Lupus Labs

Discoid lupus2

These patients rarely progress to SLE (5%)

Rarely have systemic disease

Treatment: sunscreen, topical steroids, intralesional steroids, hydroxychloroquine

Referrals as indicated

Discoid Lupus

Other papulosquamous diseases psoriasis

Other Papulosquamous Diseases: Psoriasis




Well-demarcated erythematous plaques

Thick white or silvery scale

Knees and elbows classically, can be scalp only or diffuse

Also favors gluteal cleft, navel



Not very itchy

Scale is thicker and whiter than with fungal infection

Less scaly in moist areas (in body folds) or if partially treated


Psoriasis of scalp

Psoriasis of scalp



Not psoriasis cutaneous t cell lymphoma

NOT psoriasis-cutaneous T cell lymphoma

Not psoriasis ctcl does not have thick scale

Cutaneous T-cell lymphoma

Could mimic psoriasis

Atypical locations

Biopsy should differentiate

Refer skin problems that are atypical or do not resolve as expected

Not psoriasis - CTCL: does not have thick scale

Allergic contact dermatitis

Allergic Contact Dermatitis

Allergic contact dermatitis1

Localized to area of contact

Scaly erythematous plaques

Can be blistering

On eyelids, can be due to nail polish

Allergic Contact Dermatitis

Allergic contact dermatitis2

Allergic Contact Dermatitis

Allergic contact dermatitis fragrance

Allergic Contact Dermatitis-fragrance

Allergic contact dermatitis diethylthiourea in scuba diving gear

Allergic Contact Dermatitis-diethylthiourea in scuba diving gear

Allergic contact cinnamon

Cinnamon often used as flavoring agent in gum or toothpaste

Allergic Contact-cinnamon

Allergic contact dermatitis3

Identify and avoid allergen if possible

Increase moisturization of skin

Topical steroid as needed

Rarely oral steroid if severe

Allergic Contact Dermatitis

Allergic contact poison oak

Linear blisters are classic for allergic contact dermatitis due to poison ivy

Allergic Contact-Poison Oak

Allergic contact dermatitis more subtle

Allergic Contact Dermatitis-more subtle

Seborrheic dermatitis

Erythematous patches on skin

Thick, yellow greasy scale

Seborrheic distribution: eyebrows, sides of nose, nasolabial folds, ear canals, chest

More severe in patients with HIV or Parkinson’s disease

Seborrheic Dermatitis

Seborrheic dermatitis1

Nasolabial fold

Chin area

Ear canal

Seborrheic Dermatitis




Superficial fungal infection of skin


Tinea corporis

Tinea named by location: tinea capitis, tinea corporis, tinea manum, tinea pedis, tinea barbae (beard), tinea cruris (body fold especially groin and pubic area), tinea unguium of nails (onychomycosis)

Tinea corporis

Tinea faceii

Erythematous annular plaques

Not as well-demarcated as psoriasis

Scaly, itchy

Involved areas tend to fade centrally

Treat with topical antifungal if limited area or oral agent if extensive

Tinea faceii

Tinea corporis1

Tinea Corporis

Tinea capitis

Causes itching and scaling of scalp

More common in children

Hair may break just beyond follicle

Often more than one family member affected

Can be severe and cause hair loss which can be scarring (loss of follicles)

Tinea Capitis

Tinea capitis1

Tinea Capitis

Tinea pedis

Tinea pedis

Tinea more subtle

Tinea-more subtle

Atopic dermatitis

Atopic Dermatitis

Atopic dermatitis eczema

Atopic Dermatitis (Eczema)

Nummular eczema

Nummular Eczema

Severe atopic dermatitis

Severe Atopic Dermatitis

Atopic dermatitis1

Our Recommendations:

Bathe in tepid water with mild soap

Moisturize skin frequently with vaseline or other thick cream

Topical steroids as needed for control

Rarely treated with oral immunosuppressive

Atopic Dermatitis

Benign growths of the skin

Benign Growths of the Skin

  • There are many: skin tags, cysts, lipomas, dermatofibromas, warts, keloidsand many others

  • One of the most common in adults in seborrheic keratosis

Seborrheic keratosis

Seborrheic Keratosis

Seborrheic keratoses

Seborrheic Keratoses

Seborrheic keratosis1

Verrucous (warty looking) tan to black stuck-on appearing growth

Common on back, chest, abdomen, but may be anywhere

May be multiple or single

Not necessary to remove; treat with cryotherapy or electrodessication if symptomatic or as cosmetic procedure

Treatment can cause a hypopigmented spot or scarring

Seborrheic Keratosis

Moles and melanoma

Moles and Melanoma

Normal moles nevi

Normal Moles (nevi)

Normal nevi


Regular Borders

One color or shades of brown

Smaller size , less than 6 mm, although can be larger

Do not grow or change

Develop new nevi up to age 30’s

Normal Nevi

Dysplastic nevus

Dysplastic nevus

Dysplastic nevus1

Dysplastic Nevus

Dysplastic nevus2

Irregular borders

May have more than one color

If it meets two or more of the criteria for melanoma, we may remove it

Dysplastic Nevus

Dysplastic nevus syndrome

Multiple dysplastic nevi

Familial (also known as Familial Atypical Mole and Melanoma Syndrome FAMM)

Melanoma common in one or more first or second degree relatives

Histologic criteria

Many cases linked to mutations in the CDKN2A gene, which codes for p16 (a regulator of cell division)

Difficult to evaluate visually because have 50 or more moles

Annual examinations by dermatologist plus frequent self-monitoring for change in moles

“Mole mapping” (digital imaging at UNC) if prior melanoma or if available

Dysplastic Nevus Syndrome






Most common type is superficial spreading

Tends to grow wide before it grows deep

Look for the “ugly duckling” mole-one that is different than the patient’s other moles




Dermatology for internists

Lentigo maligna melanoma

Occurs most often on head and neck

Usually evolves slowly in older patients with significant sun damage






Irregular BORDERS

Colors (more than one)

Diameter (more than 6 mm)

Evolving-very important


Melanoma more subtle

Melanoma-more subtle





Nodular melanoma

Grows rapidly (6-8 weeks)


Prognosis related to depth so worse prognosis than superficial melanoma

Nodular Melanoma

Amelanotic melanoma

Lacks pigment so may not be recognized as melanoma

Amelanotic Melanoma

Actinic keratoses

Actinic keratoses

Actinic keratoses1


Scaly erythematous macules in sun-damaged skin

Persistent scaly areas-patient scratches them off and they recur

Treated with liquid nitrogen or topical 5-fluorouracil or imiquimod

Actinic keratoses

Basal cell carcinoma

Basal Cell Carcinoma

Basal cell carcinoma1

Pearly papule with rolled borders

Has central dell (indentation)-will erode with time and form ulcer


Slow growing

Extremely rare to metastasize but can erode bony structures

Can be pigmented

Basal Cell Carcinoma

Basal cell carcinoma2

Basal Cell Carcinoma

Pigmented basal cell carcinoma

Pigmented Basal Cell Carcinoma

Basal cell carcinoma more subtle morpheaform looks like a scar

Basal Cell Carcinoma-more subtle (morpheaform: looks like a scar)

Squamous cell carcinoma

Squamous Cell Carcinoma

Squamous cell carcinoma1

Enlarging scaly, crusty plaques

Not the thick white scale of psoriasis

Not symmetrical on the body (unlike psoriasis)

Squamous cell or basal cell carcinomas may present as a non-healing spot (allow 4 weeks to heal: if it doesn’t , then biopsy)

Squamous Cell Carcinoma

Outlier topic

Outlier Topic

Pyoderma gangrenosum

Pyoderma Gangrenosum

Pyoderma gangrenosum1

Not all ulcers are infectious

Diagnosis of exclusion: rule out infection and tumor

Starts as a small red papule, then spreads into ulcer

Occurs in healthy-looking people (abdomen and legs), can occur anywhere including in the mouth

Tendency to occur in patients with inflammatory bowel disease but idiopathic in 50%

Spreads to surrounding tissues if debrided or excised

Responds to topical or oral steroids

Pyoderma Gangrenosum

Referrals to dermatology

Referrals to Dermatology

  • Any new growth that you are suspicious about

  • Refer blistering processes early

  • A rash (an eruption) in a body fold might be fungus or yeast, so an antifungal cream might be worth a trial

  • Consider a trial of over the counter cortisone or topical triamcinolone for body lesions that you believe may be a transient dermatitis or eczema (we prefer ointments over creams)

  • Refer when a skin lesion is growing or does not resolve with usual treatment

  • Refer suspected melanoma promptly

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