Papules, Scales, Plaques and Eruptions

Morphea (Late Stage)

Morphea is localized scleroderma confined to the skin. It most commonly affects the trunk but also occurs on the face and extremities. The four clinical variants include plaque-type morphea, generalized morphea, linear morphea (en coupe de sabre), and pansclerotic morphea of children (morphea profunda). This is a patient with late stage morphea on the right leg presenting as linear depressed yellowish to white hard plaques with erythematous margins.

Morphea (Early)

Morphea is localized scleroderma confined to the skin. It most commonly affects the trunk but also occurs on the face and extremities. The four clinical variants include plaque-type morphea, generalized morphea, linear morphea (en coupe de sabre), and pansclerotic morphea of children (morphea profunda). Early morphea (shown here) on the left leg presenting as an erythematous plaque.

Verrucous Papules

Verrucous papules on the periungal region of a child's fingers.

Sweet's Syndrome

Sweet's syndrome. Erythematous plaques and nodules with central bullous changes on a child's knee.

Perioral Dermatitis

Perioral dermatitis. Scattered inflammatory papules, erythema, and scale in a child who has been applying topical steroids to the area.

Morbilliform Drug Eruption on Face

Drug hypersensitivity reaction. Morbilliform rash eventually spread to the face and extremeties of the same child.

Morbilliform Drug Eruption

Drug hypersensitivity reaction. Morbilliform rash on the trunk occuring 1 week after the administration of a systemic cephalosporin.

Lichen Simplex Chronicus

Lichen simplex chronicus. Hyperpigmented, lichenified plaque with accentuated skin lined caused by repeated rubbing of the area. Lichen simplex chronicus (LSC) is a localized, well-circumscribed area of lichenification (thickened skin) resulting from repeated rubbing, itching, and scratching of the skin. It can occur on normal skin of individuals with atopic, seborrheic, contact dermatitis, or psoriasis.

Iododerma and Bromoderma Granulomatous Reaction

Granulomatous reaction caused by a bromide. Another baleful characteristic of drug eruptions from halides is persistence and extension of reaction once it occurs. The reason for such persistence or extension, even when a known source of the offending drug is removed, is the wide dispersion of occult iodine or bromine salts in foods, in the environment, and indeed in the body's own chemistry. Iodine, for example, is a constituent of thyroid hormone.

Iododerma and Bromoderma

Iododerma and bromoderma. Iodides and bromides are drugs that can cause severe adverse cutaneous reactions, and of these, the worst are acneiform, furuncular, carbuncular, chancriform, pyodermatous, or granulomatous. Iodides and bromides are widely distributed, not only in foods and in the environment but also in proprietary and formally prescribed medicaments. These figures are of still relatively minor consequences of adverse reactions from the two halides, of which bromides are usually worse than iodides. Lesions like those of acne or folliculitis caused by an iodide are shown.

Gingival Hyperplasia from Phenytoin

Gingival hyperplasia from phenytoin. The mechanisms of adverse reactions to drugs vary. Some, like the urticarial or eczematous, are clearly based on an allergic or immunologic mechanism; others are utterly obscure in mechanism. Such is the gingival hyperplasia caused by phenytoin. Since it occurs in almost all patients receiving the drug, all one can say is that the effect probably is within the normal pharmacologic action of the drug.

Gianetti-Crosti Syndrome on Elbow

Gianetti-Crosti syndrome. Erythematous papules on the elbows.

Gianetti-Crosti Syndrome

Gianetti-Crosti syndrome. Monomorphous papules coalescing into plaques on the cheeks of a child.

Geographic Tongue

Geographic tongue. There is a peculiar condition of the tongue that takes the form of denudations of the lingual surface in patches of redness that shift in position from time to time over hours and days. The cause of the condition is not known; there may be some relationship to psoriasis. No treatment is effective. The condition is largely asymptomatic except for slight tingling when sharp food is taken.

Fixed Drug Eruption

Fixed drug eruption. A large red-violet plaque on the arm of a child.

Erythema Toxicum Neonatorum Eruption

The eruption shown was unusual in that it was so widespread and vesiculopustular. Occasionally, this unimportant eruption must be differentiated from more serious infectious processes, such as neonatal herpes simplex. Tzanck smear of a pustule of erythema toxicum neonatorum will reveal numerous eosinophils but no multinucleated giant cells or bacteria. Occasionally, peripheral eosinophilia is also present. The cause of this condition is not known, and it resolves spontaneously within 10 days. No treatment is required.

Erythema Toxicum Neonatorum

Erythema toxicum neonatorum. This very common and completely benign condition usually arises in the first 2 days of life. It is seen in about half of healthy newborns and occurs less frequently in preterm infants. The lesions are erythematous macules, within which papules and pustules may develop. The trunk is the most common site, but all other body surfaces, except for the palms and soles, may be involved. Occasionally' these lesions may occur in plaques. The eruption shown in Fig. 1-1 began 2 hours after delivery and involved the face and trunk.

Rash from Poisonous Plants

Poison ivy, poison oak and poison sumac are plants that contain an irritating, oily sap called urushiol. Urushiol triggers an allergic reaction when it comes into contact with skin, resulting in an itchy rash, which can appear within hours of exposure or up to several days later. A person can be exposed to urushiol directly or by touching objects -- such as gardening tools, camping equipment and even a pet's fur -- that have come into contact with the sap of one of the poison plants. The rash that results from the poison plants is a form of allergic contact dermatitis. (Dermatitis is swelling and irritation of the skin.) Skin is not automatically sensitive to urushiol. Sensitivity builds up after the skin is exposed to the substance. When initially exposed to urushiol, the skin alerts the immune system of the presence of the irritating chemical. (Usually, no visible reaction will occur the first time a person comes in contact with a poison plant.) The immune system then prepares a defensive reaction for the next time the skin encounters the substance. This sensitizes the skin so that new contact with urushiol causes an allergic reaction.

Poison Ivy

Poison ivy has characteristic shiny, red, three-leaf configuration. Poison ivy produces urushiol, a resin that can cause an allergic reaction. Symptoms and signs of poison ivy rash include itchy, red bumps or blisters. Compresses with cool water or Burow's solution may help to dry the rash faster. Severe cases may require treatment with oral steroids.

Diaper Rash

Almost every baby will get diaper rash at least once during the first 3 years of life, with the majority of these babies 9-12 months old. This is the time when the baby is still sitting most of the time and is also eating solid foods, which may change the acidity of the bowel movements. Diaper rash appears on the skin under a diaper. Diaper rash typically occurs in infants and children younger than 2 years, but the rash can also be seen in people who are incontinent or paralyzed.

Cradle Cap

Cradle cap (also called seborrheic dermatitis) is a rash that begins as scaling and redness on a baby's scalp. This condition is a noninfectious skin condition and is a form of eczema. Seborrheic dermatitis is common in infants, usually beginning in the first weeks of life and slowly disappearing over a period of weeks or months. The condition rarely is uncomfortable or itchy. The precise cause of the rash is not known; however, Pityrosporum ovale (a yeast) is believed to play a role in this condition.

Pityriasis Rosea 2

Pityriasis rosea: A common mild rash of unknown origin that can appear on a person of any age (most commonly at 10-35 years of age), may last from several weeks to several months, often begins with a "herald" patch, a large single pink patch on the chest or back and, within a week or so, more pink patches on the torso, arms and legs. There may be itching, especially when overheated. Treatment may include medications for the itching and soothing lotions or lubricants, and lukewarm rather than hot baths.

Pityriasis Rosea 1

Pityriasis rosea: A common mild rash of unknown origin that can appear on a person of any age (most commonly at 10-35 years of age), may last from several weeks to several months, often begins with a "herald" patch, a large single pink patch on the chest or back and, within a week or so, more pink patches on the torso, arms and legs. There may be itching, especially when overheated. Treatment may include medications for the itching and soothing lotions or lubricants, and lukewarm rather than hot baths.

Darier's Disease

Darier's disease, or keratosis follicularis, is a pruritic, autosomal dominant inherited disease with multiple discrete scaling, crusted, and pruritic papules; it is malodorous and disfiguring and also involves the nails and mucous membranes. It is characterized by premature and abnormal keratinization and loss of epidermal adhesion with acantholysis. It usually persists throughout the lifetime of the patient. Primary lesions are reddish, scaling and crusted papules that, when stroked, feel warty. Where crusts have been removed there are slit-like erosions that are later covered by hemorrhagic crusts.

Palmar Pustulosis

Deep-seated, dusky-red macules and creamy-yellow pustules progress to hyperkeratotic/crusted papules. Lesions are confined to the palms and/or soles and hardly extend over the wrist line. Because of the pustules, the disorder is commonly mistaken for a bacterial or, if confined to a single digit, for herpetic infection.

Erythema Multiforme 3

The type of bulla that may occur in erythema multiforme is shown here. Mucosal lesions are not uncommon. Erythema multiforme is a self-healing disease, with an average duration of about 2 weeks. Herpes simplex infection is by far the most common etiologic agent. Finally, a wide variety of drugs, most commonly the sulfonamides, may cause this syndrome.

Erythema Multiforme 2

Erythema multiforme tends to be acral in distribution, and the dorsum of the hand is a particularly common location.

Erythema Multiforme 1

This disorder is termed multiforme because the morphology of its lesions is so variable. The primary lesion is most often an erythematous macule that evolves into a papule. Early in the course, these lesions may easily be mistaken for urticaria. As the lesions enlarge, they form round or irregularly shaped plaques. Concentric circles of erythema and dark gray discoloration may evolve, forming the typical “target” lesion of erythema multiforme. The “target” lesions may coalesce and develop annular or serpiginous borders. Figure 13-8 is a close-up of the target-like quality of the variably sized and shaped plaques.

Xanthomatosis 2

The lesions illustrated here are typical of xanthoma striatum palmare, a form of planar xanthoma. This patient also has biliary cirrhosis. Note how the yellowish papules and plaques follow the creases of the fingers and the palmar folds. The familial hyperlipidemias, particularly types II, III, and V, may present with an identical clinical picture. Patients with these disorders are at high risk for ischemic heart disease.

Xanthomatosis 1

Xanthomas are papules or nodules of the skin or mucous membranes that contain lipids. The appearance of xanthomas during childhood should prompt a thorough search for underlying systemic disease. The yellowish papules seen in here are a form of planar xanthoma. These may occur on any part of the body and may be an indicator of a hereditary lipoproteinemia, diabetes mellitus, or liver disease. Multiple myeloma and histiocytosis X are less common etiologies. The patient pictured here has biliary cirrhosis.

Lichen Planus (Oral)

Lichen planus (LP) is a common inflammatory disease involving the skin and mucous membranes. Many clinical variants exist that include atrophic, ulcerative, bullous, annular, linear, inverse, hypertrophic, lichen planopilaris, actinic LP and LP pigmentosus. Oral lichen planus at baseline (left). Two month follow-up after 18 treatments with excimer laser administered weekly (right).

Lichen Planus 2

A small percentage of patients with lichen planus develop nail involvement. The severity varies. Some children develop only mild thinning or ridging of the nail plate. Others have a severe nail dystrophy, with pterygium formation and complete and permanent nail loss. A case where the nails are destroyed is pictured here. Rarely, there may even be severe lichen planus of the fingernails and toenails without skin involvement. In any case, attempts to treat the severe forms of nail disease in lichen planus are rarely successful.

Lichen Planus 1

This condition is a pruritic eruption of unknown etiology. It is not uncommon in childhood. This illustration shows representative lesions of lichen planus on a most common site, the wrists. The primary lesion consists of a flat-topped, polygonal, violaceous papule 2–6 mm in diameter. The characteristic shiny appearance of the individual papules is seen. This figure also illustrate the tendency for the solitary lesions to form confluent plaques. Exaggerated surface markings in the overlying skin (Wickham's striae) may also be evident but are difficult to appreciate. The forearms, the middle of the back, and the anterior surfaces of the lower extremities are other common locations. On the legs, lesions may become markedly hypertrophic and plaque-like. Diagnosis can sometimes be confirmed by the presence of oral lesions. Typically, there are small white papules in a reticular pattern on the buccal mucosa. The tongue, lips, and palate may also be involved.

Psoriatic Arthritis

Psoriatic arthritis is a specific condition in which a person has both psoriasis and arthritis. Psoriatic arthritis is an autoimmune disease, meaning that the immune system is misdirected to cause inflammation of one's own tissues. Rarely, a person can have psoriatic arthritis without having skin psoriasis. Moreover, the arthritis can precede the psoriasis by months or years, or present after years of psoriasis.

Psoriasis of the Scalp

The scalp may have fine, dry, scaly skin or have heavily crusted plaque areas. The plaque can flake off or peel off in crusted clumps. Sometimes psoriasis of the scalp is confused with seborrheic dermatitis. A key difference is that in seborrheic dermatitis, the scales are greasy looking, not dry.

Erythrodermic Psoriasis

This is the least common type of psoriasis and can be quite serious. A very large area of the body, if not most of the body, is bright red and inflamed. The body can appear to be covered in a peeling red rash. The rash usually itches or burns.

Pustular Psoriasis

Pustular psoriasis is an uncommon form of psoriasis. People with pustular psoriasis have clearly defined, raised bumps on the skin that are filled with pus (pustules). The skin under and around these bumps is reddish. Pustular psoriasis may cause large portions of your skin to redden. The skin changes that occur before, during, or after an episode of pustular psoriasis can be similar to those of regular psoriasis.

Inverse Psoriasis

Inverse psoriasis consists of bright red, smooth (not scaly) patches found in the folds of the skin. The most common areas are under the breasts, in the armpits, near the genitals, under the buttocks, or in abdominal folds. These irritated and inflamed areas are aggravated by the sweat and skin rubbing together in the folds. Yeast overgrowth, common in skin folds, may trigger the skin lesions of psoriasis.

Guttate Psoriasis

Guttate psoriasis is a type of psoriasis that looks like small, salmon-pink drops on the skin. The word guttate is derived from the Latin word gutta, meaning drop. Usually there is a fine scale on the droplike lesion that is much finer than the scales in plaque psoriasis, the most common type of psoriasis. The trigger to the disease is often a preceding streptococcal (bacterial) infection. The eruption of the lesions on the skin usually happens about two to three weeks after the person has strep throat. The outbreak can go away and not reoccur.

Psoriasis Vulgaris Plaque

Psoriasis vulgaris, Koebner phenomenon. Well-delineated erythematous plaque with a silvery-white scale characteristic of psoriasis.

Psoriasis Vulgaris Erythematous

Psoriasis vulgaris. Well-delineated erythematous plaque located on the elbow of a child with psoriasis.

Psoriasis Vulgaris Palms

Silvery-white scaly plaque, sharply demarcated, of irregular configuration. On palms and soles the lamellar scales are more adherent than on other parts of the body and only their removal will reveal the reddish inflammatory base.

Psoriasis Vulgaris Soles

Well-demarcated, erythematous plaques with thick, yellowishlamellar scale and desquamation on sites of pressure arising on the plantar feet; similar lesions were present on the palms.

Psoriasis Vulgaris

Psoriasis vulgaris, scalp and nail findings. Pinpoint pits and distal onycholysis (so-called "oil-spot" discoloration) are seen in the fingernails of a child with psoriasis. Psoriasis vulgaris is the medical name for the most common form of psoriasis ("vulgaris" means common). About 80% of people with psoriasis have this type. It is also called plaque psoriasis because of the characteristic plaques on the skin: well-defined patches of red raised skin that can appear on any area of skin, although the knees, elbows, scalp, trunk and nails are the most common locations. The flaky silvery white buildup on top of the plaques is called scale; it is composed of dead skin cells. This scale comes loose and sheds constantly from the plaques. Skin affected with psoriasis is generally very dry, and other possible symptoms include skin pain, itching and cracking.

Psoriasis 3

This figure shows the erythema, scaling, and thickening of portions of the thumb and soles that are very common in both children and adults with psoriasis. Therapy of psoriasis is based on the skillful use, either alone or in combination, of a number of therapeutic agents. The most effective are topical steroids, tars, keratolytics, ultraviolet light, and topical calcipotriol and tazarotene in older patients. Children with simple plaque psoriasis can often be managed with short-contact anthralin preparations. When topical steroids are used, it is important to employ the least potent preparation that is effective and to avoid the use of fluorinated steroids on the face and in intertriginous areas. Finally, careful exposure to sunlight during the summer months and artificial ultraviolet light at other times is enormously beneficial in selected patients with extensive involvement.

Psoriasis 2

More than one-quarter of all individuals with psoriasis develop their disease during childhood or adolescence. The degree of involvement is extremely variable; some children develop only a few localized plaques, while others suffer from generalized skin disease and severe arthritis. Pictured are the typical lesions of psoriasis; the plaques have a red-to-orange hue, are scaly, and are sharply demarcated from the surrounding skin. The symmetrical involvement of the knees is a common pattern; elbows and buttocks are other favored locations for plaques like these.

Psoriasis 1

Psoriasis: A reddish, scaly rash often located over the surfaces of the elbows, knees, scalp, and around or in the ears, navel, genitals or buttocks. Psoriasis is an autoimmune disease that is mediated by T lymphocytes. It is also a very common disease, Chronic plaque psoriasis affects approximately 2% of people around the world. About 10-15% of patients with psoriasis develop joint inflammation (inflammatory arthritis). Treatment options include topical steroid creams, tar soap preparations, and exposure to ultraviolet light.

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