A Clinician's Guide to Dermatologic Differential Diagnosis, Volume 1: The Text (Encyclopedia of Differential Diagnosis in Dermatology)

735 Pages·2006·5.25 MB·English

by  Paul Schneiderman

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A Clinician’s Guide to
Dermatologic
Differential Diagnosis
Volume 1
The Text
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Dedications
There are a great number of people who made significant contributions to my personal and
professional development,provided me with nurturing love and guidance,the opportunity to
succeed,and valuable professional support which has enabled me to make a difference for my
patients and my specialty.I am deeply and humbly indebted to them all.It is to these members
of my life family that this book is lovingly dedicated.
Miriam and Morris Schneiderman Frank Call,MD
Steven and Arthur Schneiderman Edward W.Hook,MD
Judy Schneiderman Dwight Wooster,MD
Hyman Karmen David Stone,MD
Arthur and Marcia Karmen Kenneth E.Greer,MD
Etta and Louis Biblowitz Richard L.Edelson,MD
Iris and Jerry Schwartzbaum Edward P.Cawley,MD
Kenneth Barnett,PhD Louis E.Harman,MD
Eric Tash Peyton E.Weary,MD
Bette Schneiderman Larry Legum,MD
Andy and Scott Schneiderman Barry S.Coller,MD
Judy and Morty Eydenberg Steven R.Kohn,MD
John J.Gullo,MD Larry Bilsky,MD
Robert O.Knapp,MD Myco-authorMarcE.Grossman,MD
Paul I Schneiderman
For my favorite girls
Leslie,Andrea,and Julie
Marc E Grossman
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A Clinician’s Guide to
Dermatologic
Differential Diagnosis
Volume 1
The Text
Paul I Schneiderman
MD
Clinical Professor of Dermatology
College of Physicians and Surgeons
Columbia University, New York, NY, USA
Marc E Grossman
MD
Professor of Clinical Dermatology
College of Physicians and Surgeons
Columbia University, New York, NY, USA
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ISBN-10:0-415-39052-4
ISBN-13:978-0-415-39052-1
Also available
Volume 2:The Atlas (ISBN-10:0-415-39051-6;ISBN-13:978-0-415-39051-4)
Volumes 1 and 2 (ISBN-10:0-415-40263-8;ISBN-13:978-0-415-40263-7)
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Contents
Dedication ii Cerebriform lesions 113
Foreword viii Chalky material extruded from lesion 115
Introduction ix Cheilitis (crusted lips) 115
Acknowledgment x Chest wall tumors 117
Cleft lip/palate – associated skin disorders 118
List of diagnostic conditions: Cobblestone appearance of the oral mucosa 118
Cobblestone appearance of skin 120
Abscess 1 Conjunctivae, pigmented lesions 123
Acanthosis nigricans 5 Cutaneous horns 124
Acneiform lesions 7 Cutis laxa-like appearance 125
Acral cyanosis 12 Cysts, with or without drainage 127
Acral erythema 15
Acral erythema and scale with or without a linear cutoff 18 Dermatitis 130
Acral papules and nodules;knuckle papules; 19 Dermatitis, facial, pediatric 136
papules, digital Dermatitis, periorbital 138
Acromegalic features 26 Dermatitis, periorificial 140
Acro-osteolysis 26 Dermatographism 142
Ainhum 27 Dimples 143
Alopecia 28 Dyschromatosis (hypo- and 144
Alopecia, eyebrows 39 hyperpigmentation)
Alopecia in neonates, infants or toddlers 41 Dyshidrosis 145
Angioedema 42
Angiokeratoma corporis diffusum 43 Ear, hard (petrified auricles) 147
Annular lesions of the penis 43 Ear lesions 147
Annular lesions with surface changes 43 Ears, red, with or without nodules 155
Annular lesions without surface changes 48 Edema 157
Annular scars 52 Edema, hands and/or feet 162
Aphthous stomatitis 53 Edema, head 165
Arthritis and rash 54 Edema, legs 166
Atrichia and nail abnormalities 62 Erosions (superficial ulcers) 169
Atrophic glossitis 62 Erythrodermas 172
Atrophic lesions 63 Erythrodermic infant 176
Eschars 177
Basal cell carcinoma – syndromes 73 Exanthem 177
‘Black’dermatologic entities 74 Exfoliation (desquamation) 184
Black oral lesions 76 Eyelid lesions 186
Blaschko-esque entitites 76 Eyes, red, and rash 194
Blue spots 79
Blueberry muffin lesions, neonate 85 Facial dermatitis, scaly 201
Breast asymmetry 85 Facial edema 203
Breast lesions 86 Facial papules 205
Breast hypertrophy and breast masses 87 Facial papules and plaques 212
Buffalo hump 89 Facial plaques, scarring and non-scarring 214
Bullae and/or vesicles 89 Facial scars 218
Bullae, hemorrhagic 99 Facial ulcers 219
Bullae, hemorrhagic, septic 102 Fibromatoses of children 221
Bullae in newborn 103 Figurate erythemas 221
Bullae of infants and children 103 Fingertip lesions 222
Bullae of the fingers or toes 105 Fingertip necrosis 224
Burning tongue 108 Fingertip ulcers 226
Butterfly rash 108 Flushing disorders 227
Follicular plugging 230
Café au lait macules, associations 110 Foot ulcers 230
Cellulitis in the immunocompromised host 112 Freckling of the hands 231
v
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vi A CLINICIAN'S GUIDE TO DERMATOLOGIC DIFFERENTIAL DIAGNOSIS, VOLUME 1
Gingival hyperplasia 231 Nipple dermatitis 363
Gingivitis 234 Nipple lesions, including nipple with multiple papules 364
Nodules, congenital 366
Hair nodules or nits (particulate matter) 237 Nodules, foot 367
Hair, premature graying 237 Nodules, juxta-articular 370
Hemihypertrophy 239 Nodules, knee 372
Herpetiform lesions 239 Nodules, multilobulated 373
Heterochromic irides 240 Nodules, multiple, subcutaneous 376
Hyperhidrosis 240 Nodules, red on the extremities 378
Hyperkeratotic lesions 245 Nodules, red, face 385
Hyperkeratotic lesions of the feet 249 Nodules, red, hand 387
Hyperkeratotic lesions of the hands 252 Nodules, skin-colored 389
Hyperkeratotic papules of the nipple 254 Nodules, ulcerated 397
Hyperpigmentation in Blaschko’s lines 254 Nodules, unspecified location 401
Hyperpigmentation, diffuse 255 Nodules, red or violaceous, with vascular appearance 403
Hyperpigmentation, paronychial 258 No fingerprint syndromes 410
Hyperpigmentation, patchy 258 Normal skin/barely perceptible plaque 411
Hyperpigmentation, segmental or zosteriform 265
Hyperpigmented lesions, discrete annular 266 Onycholysis 411
Hypertrichosis, generalized 268 Oral mucosa, blue pigmentation 413
Hypertrichosis, localized 271 Oral mucosa, cysts 414
Hypohidrosis (anhidrosis) 277 Oral mucosa, nodules 414
Hypopigmented patches or plaques 280 Oral mucosa, ulcerations 418
Hypoplasia of distal phalanges 285 Oral mucosa, verrucous and vegetating lesions 423
Oral mucosal hyperpigmentation 424
Ichthyosiform eruptions:acquired ichthyosis 285 Osteoma cutis 426
Immune deficiency syndromes with pyodermas 290
Inguinal lymphadenitis 292 Painful tumors 426
Intertrigo, including diaper dermatitis 292 Palatal necrosis 427
Iris lesions, pigmented 296 Palmar erythema 428
Palmar or plantar nodules 430
Kaposi’s sarcoma 297 Palmar pits and punctate keratoses/dyshidrosis-like 431
Kinky hair 297 lesions
Knuckle papules 297 Palmoplantar keratodermas 433
Knuckles, pebbly with scarring:‘Why do my 299 Palmoplantar keratodermas – alternative classification 442
hands look so old?’ Palmoplantar pustules 443
Papules and nodules, hyperpigmented (with or
Lacrimal gland, enlarged 300 without hyperkeratosis) 443
Lentigines 300 Papules, crusted 446
Leonine facies 302 Papules, digital 449
Leukoderma, guttate 303 Papules, dirty brown 452
Leukonychia 304 Papules, distal, digital, white 453
Leukoplakia 305 Papules, facial, solitary 453
Linear hypopigmentation 307 Papules, flat-topped 455
Linear lesions 307 Papules, follicular, including folliculitis 458
Linear lesions along veins 315 Papules, hyperkeratotic 463
Lip lesions, pigmented 317 Papules, hyperpigmented with hypertrichosis 468
Lip papules 318 Papules, periorbital 468
Lip pits 320 Papules, red 470
Lips, swollen 320 Papules, skin-colored 477
Livedo reticularis with or without necrosis 323 Papulosquamous eruptions 480
Papulovesicular dermatitis in infants 481
Macrodactyly (enlarged digit) 327 Paraneoplastic dermatoses 481
Marfanoid habitus 330 Paraproteinemias, cutaneous manifestations 483
Masses of the head and neck 331 Paronychia 483
Melanoma – clinical simulators 334 Parotid gland enlargement 485
Melanonychia 335 Particulate matter/exfoliation 487
Micronychia and anonychia 336 Pedunculated (polypoid) lesions 488
Midline facial nodules of children 338 Penile lesions 490
Midline nasal masses 338 Penile ulcers 496
Milia and milia-like lesions (fine white papules) 338 Perianal dermatitis and hypertrophic plaques 498
Mucinoses 340 Perianal ulcers, single or multiple 501
Periorbital edema/erythema/dermatitis 502
Nasal infiltration or enlargement 341 Photoeruption and/or seborrheic dermatitis-like eruption 508
Nasal septal ulcerations/perforations/rhinophagic 343 Pityriasis rosea-like eruptions 518
ulceration Plantar erythema 519
Neck lesions 345 Poikilodermas of childhood 521
Neck papules 350 Poikilodermas of adulthood 522
Necrosis 353 Poliosis – localized or generalized (canities) 523
Nevi:syndromes associated with nevi 361 Polydactyly 523
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CONTENTS vii
Pore 524 Tattoo, palpable:lesion in a tattoo 633
Port wine stain 524 Teeth 633
Preauricular sinuses (ear pits) 525 Telangiectasias – congenitial disorders 636
Premature aging syndromes 525 Telangiectasias – acquired disorders 638
Pruritic tumors 527 Tongue, enlarged (macroglossia) 640
Pruritus, anal 527 Tongue, hyperpigmentation 642
Pruritus, erythematous papules 528 Tongue, multilobulated 643
Pruritus, generalized (without primary skin lesions) 530 Tongue, red 644
Pruritus vulvar 533 Tongue, scrotal 645
Pseudoxanthoma elasticum-like changes 533 Tongue, ulcer 646
Psoriasiform dermatitis 534 Transient blisters in infants 648
Psoriasiform plaque, focal or solitary 537 Trichomegaly 648
Pterygia 539 Tropical fever and rash 648
Pterygium of the nail 539 Tumors, giant 650
Puberty, delayed 540
Puberty, premature 542 Ulcers 652
Purpura 543 Ulcers, leg 661
Purpura, neonatal 554 Ulcers of the leg in a young patient 666
Purpuric rash and fever 554 Umbilical lesions 667
Pustular and vesicopustular eruptions in newborn 557 Umbilical nodules 670
Pustules and pustular eruptions 558 Umbilicated lesions 671
Unilateral foot edema 674
Red elbow 565 Urticaria and urticaria-like lesions 674
Red face 566 Uvula, enlarged 679
Red feet 569
Red nose 571 Vasculitis, disease associations 680
Red patch 573 Vasculitis, granulomatous 680
Red plaques 579 Vasculitis, leukocytoclastic 680
Redundant skin 588 Vasculitis, thrombotic 681
Reticulated eruptions 590 Vasculitis, types 682
Reticulated hyperpigmentation 595 Vegetating lesions 683
Rosette lesions 596 Verrucous lesions of the legs 684
Verrucous lesions, periungual 685
Scalp cysts 596 Verrucous plaques 686
Scalp dermatitis 597 Vulva, hypertrophic and/or edematous lesions 691
Scalp nodules 599 Vulvar erythema/pruritus 693
Scalp, red plaques 604 Vulvar papules and nodules 694
Scarring of neck 604 Vulvar ulcers 697
Scar and lesions in scars 605
Sclerodermoid changes 605 White feet 699
Scrotal nodules 610 White macules 700
Scrotal nodules with erosions 612 White papules or nodules 706
Scrotal ulcerations 612
Serpiginous lesions 614
Xanthomatous lesions 708
Short stature 616
Xerosis – associations and causes 708
Sinus tracts 623
Spinal dysraphism, cutaneous stigmata 625
Splinter hemorrhages 625 Yellow nail syndrome 711
Sporotrichoid lesions 626 Yellow to skin colored papules of the neck 711
Spotty pigmentation of the face 627 Yellow papules and/or plaques 712
Striae distensae 627 Yellow plaque 716
Syndactyly 627 Yellow skin 717
Tail 630 Zebra stripes (zebra-like pigmentation) 718
Target lesions 630 Zosteriform lesions/segmental disorders 721
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Foreword
The specialty of dermatology has advanced over the past 35 years from one of clinical descriptions
of cutaneous disorders to encompass the fields of clinical immunology and cellular and molecular
biology with striking improvements in our ability to diagnose and treat many skin diseases which
previously were only vaguely defined or untreatable.
However, even today, the cornerstone of clinical dermatology still requires a careful and
perceptive physical exam with a detailed knowledge of the range of cutaneous clinical findings and
their associated dermatologic and systemic disorders.
Paul Schneiderman and Marc Grossman, whom I have known professionally for a total of 63
years, are two of the finest teacher/clinician/academicians in our specialty and have assembled a
comprehensive presentation of dermatologic entities in differential diagnostic format accompanied
by 4000 clinical photographs which serve as “visual orientations”for the diagnostic lists.
This opus is a life’s work in the field of clinical dermatologic teaching. The text and accompanying
atlas can be perused for ideas when the confounding patient arrives at your institution or office,and
thus, this tome will be useful for the academic dermatologist/clinician or the small town general
practitioner. The two volumes light a pathway of approach to clinical dermatology and are the result
of the combined 55 years of clinical instruction to which these two teachers of our specialty have
devoted their professional lives.
I am thrilled that their contributions to our specialty can extend beyond the confines of New
York and New Haven,and trust that all those first learning dermatology or those already well-versed
in the specialty will derive as much pleasure and knowledge from this text as all the residents and
colleagues who have been educated by these two clinician/scholars.
Richard L.Edelson,MD
Chairman, Department of Dermatology
Yale-New Haven Medical Center
New Haven, Connecticut
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Introduction
Dermatologic differential diagnosis represents a continuous challenge both to the new student and the
most seasoned practitioner. This textbook is designed to assist in the diagnosis of skin disease by
presenting a unique and comprehensive approach to differential diagnosis. We expect this book to
function as a tool to improve our readers’skills in physical examination of the skin and sharpen their
analytical thinking in dermatology.
Useful in the diagnosis of patients in emergency rooms,private offices,or hospital beds,this text is
practical for a large group of motivated diagnosticians including academicians, private practitioners,
residents in dermatology, internal medicine, or pediatrics, medical students and even self-diagnosing
patients.For the resident and student,complete lists of differential diagnoses will expand their breadth of
knowledge of human skin disease.For the experienced attending dermatologist caring for the patient with
a difficult diagnostic enigma,this reference will aid in thinking beyond initial clinical impressions.
The concept of this textbook evolved from the two authors’ team teaching of dermatology
residents over the past 26 years.Whether through the intense scrutiny of Kodachrome color slides or
examination of patients in the clinic,office,or hospital bedside,each week we presented our residents
with clinical “unknowns.”Provided with no histories or laboratory data,the residents were challenged
to rely on their clinical examination skills to generate lists of possible diagnoses based solely on the
morphology of the skin lesions and clinical settings. They quickly learned the critical importance of
accurate morphologic recognition in order to direct them to the appropriate differential diagnostic
category.The resident lists of diagnoses were then used to expand and update our original materials
and to extend the scope and content of this work.
With this teaching model, students and residents learned the importance of thorough and precise
observation as the cornerstone of dermatologic diagnosis.Hence the companion atlas with over 4000
color photographs will direct the reader to more precise pictorial descriptions paralleling the text.
The use of this book requires a fundamental knowledge of primary, secondary, and special skin
lesions as well as their pattern and distribution.The table of contents is organized into sections based
on the morphology of the skin lesions. Each section is subdivided into putative pathophysiologic
mechanisms including
autoimmune, metabolic,
congenital, neoplastic,
degenerative, paraneoplastic,
drug reactions, primary cutaneous,
exogenous agents, psychocutaneous,
infections and infestations, syndromes,
infiltrative, trauma,and
inflammatory, vascular diseases.
Some diseases and conditions fall into multiple categories. We have included those to make them
easier to find.Some entities have multiple names and have suffered from being named and renamed
over time.An attempt has been made to eliminate outdated or confusing names and to use only one
for consistency.
The content of this textbook includes rare clinical manifestations of common cutaneous
conditions and common clinical manifestations of rare cutaneous conditions. In addition there are
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