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Primary: Specific Changes Caused Directly by Disease Process


  • Macule: Nonpalpable, <1 cm
  • Patch: Nonpalpable, >1 cm
  • Papule: Solid, palpable, <1 cm
  • Nodule: Solid, palpable, 1–2 cm, dermal
  • Tumor: Solid, palpable, >2 cm
  • Plaque: Solid, palpable, >1 cm, width > thickness
  • Vesicle: Raised, clear, fluid filled, <1 cm
  • Bulla: Raised, clear, fluid filled, >1 cm
  • Pustule: Raised, pus filled
  • Wheal: Transient, palpable edema


Secondary: Nonspecific Changes Caused by Evolution of Primary Lesions


  • Scale: Accumulation of loosely adherent keratin
  • Crust: Accumulation of serum, cellular, bacterial, and squamous debris over damaged epidermis
  • Fissure: Superficial, often painful break in epidermis
  • Erosion: Loss of epidermis; heals without scarring
  • Ulcer: Loss of epidermis and part or all of dermis; heals with scarring
  • Excoriation: Linear erosion
  • Lichenification: Accentuated skin markings caused by thickening of epidermis; usually caused by scratching or rubbing
  • Scar: Fibrous tissue replacing normal architecture of dermis
  • Atrophy: Epidermal (thinning of epidermis) or dermal (decrease in the amount of collagen or causing depression of skin)

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Signs and Symptoms

  • Primary vs. secondary changes
  • Color
  • Consistency and texture
  • Mobility
  • Configuration
  • Shape
  • Well vs. ill-defined
  • Arrangement
  • Discrete
  • Localized
  • Grouped
  • Disseminated
  • Symmetry
  • Dermatomal
  • Photodistribution
  • Mucous membrane involvement
  • Contact areas
  • Flexor vs extensor surfaces
  • Koebner phenomenon: areas of previous trauma
  • How long?
  • Since birth?
  • Recurrent?
  • Sick contacts
  • Recent travel
  • Medications
  • Personal care products
  • Environmental exposures
  • Occupational exposures
  • Recreational exposures
  • Seasonal variation
  • Family history
  • Local
  • Pruritus
  • Pain and tenderness
  • Paresthesias
  • Bleeding
  • Systemic
  • Fever or chills
  • Malaise or fatigue
  • Arthritis or arthralgias

  • Risk factors: Family history, other atopic diseases (asthma, allergic rhinitis), food hypersensitivity, environmental allergens
  • Clinical manifestations: Pruritic, erythematous, scaly papules and plaques → edema, serous discharge, crusting → lichenification, hyperpigmentation, fissuring → superinfection (primarily with Staphylococcus aureus; also with HSV)




  • Infantile: Cheeks, forehead, trunk, extensor surfaces
  • Childhood: Wrist, ankle, antecubital and popliteal fossae
  • Adolescent and adult: Flexor surfaces, face, neck, hands, feet

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Clinical Features

Treatment or Prevention

S. aureus superinfection

Honey-crusted erosions, pustules, weeping, acute increase in erythema

  • Topical or oral antibiotic
  • Obtain culture

Eczema herpeticum (HSV superinfection)

  • Source of contact often adult caretaker with “cold sore”

  • First-degree lesions: Crops of vesicles on inflamed base at sites of eczema
  • Late: “punched-out” erosions
  • Common associated symptoms: Fever, malaise, irritability, intense itching, eczema flare
  • Severe: Widespread viral dissemination with multiorgan involvement
  • Stop TCS or TCI
  • Acyclovir or valacyclovir
  • Treat for secondary bacterial infection if indicated
  • Treat known contacts
  • Eye exam for periorbital involvement
  • Obtain culture &/or DFA

Long-term TCS use

  • Skin atrophy, ecchymoses, striae, telangiectasias, poor wound healing, perioral dermatitis or steroid rosacea, hypothalamus–pituitary axis suppression with systemic absorption
  • Limit use for flares only (usually <1- 2-wk intervals)
  • Use lower potency TCS for face, underarms, and groin
  • If indicated, evaluate for adrenal suppression and treat appropriately

Postinflammatory pigment changes

  • Hypo- or hyperpigmented macules or patches ...

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