Dr Saurabh

Jindal

DVT
Dermatology
2020
Clinical vignettes
Vignette 1. Dark facial colours
Brown/ Blue/ Grey
Color Site Cong/ Diagnosis
Acq
Brown Malar,nose-F>M Acq Melasma
Brown Nose (mainly), Acq Chikungunya
always a history sign
of fever + joint
pains
Black Face Cong Melanocytic
nevus
Blue Malar Cong Nevus of Ota
(unilateral),
blue sclera
Color Site Cong/ Acq Diagnosis

Blue/ Full face Acq LP pigmentosus

Grey
Red/ Lip , h/o drug Acq Fixed drug
Brown intake eruption
/Blue/
grey
Brown- Cheeks- nose – Blue/ grey- photosensitive-
photosensitive- localised- Diffuse lesions-(LP
MELASMA PIGMENTOSUS)
Brown- nose (yellow arrow) and face – not
photosensitive- always a h/o fever and joint pains-
CHIK sign(Chikungunya)
Black- face- congenital/ Black- face- congenital/
Acquired- Non hairy- Acquired- Hairy-
MELANOCYTIC NEVUS MELANOCYTIC NEVUS
Brown- face-
Blue- face- congenital-
photosensitive-
Blue sclera- Nevus of Ota
MELASMA
Pigmented spot Pigmented spot (Blue/Grey)-
(red/brown)- lip- h/o drug lip- h/o drug (eg- NSAIDS) –
(eg- NSAIDS) – Early FIXED Late FIXED DRUG ERUPTION
DRUG ERUPTION
Vignette 2. Red facial colours
 Red
Color Site Cong/ Diagnosis
Acq
Red Malar, nose- F > M, Acq SLE
photosensitive,
persistent
erythema, spares
nasolabial folds,
NOT ON EYELIDS
Red EYELIDS mainly + Acq Dermatomyos
face + neck, itis
photosensitive
 Red
Color Site Cong/ Acq Diagnosis

Red Small elevated, old Acq Cherry

patient hemangioma
Red elevated Conge Infantile
nital hemangioma
Red Flat Conge Portwine stain
nital
Red- cheeks- photosensitive
- intermittent erythema- Red- cheeks-
h/o with alcohol, emotions photosensitive- persistent
etc- ROSACEA erythema- SLE
Red- Periorbital > Cheek- photosensitive –
DERMATOMYOSITIS (Cheek > Periorbital= SLE)
Red- Flat- congenital-
Portwine stain
Red- papule/ Nodule- Red- papule- Acquired- Old
congenital- Infantile age – CHERRY ANGIOMA
hemangioma
 Vignette 3
- Hypopigmented face lesions
 Indeterminate P. alba
hansens

Normal sensations, normal Normal sensations,

sweating, atrophy+, from normal sweating, No
endemic areas atrophy, Fine scaling, h/o
atopy+
Pityriasis versicolor
 Vignette 4
- Hypopigmented truncal lesions
 P. versicolor

Perifollicular hypopigmentation, Normal sensations,

fine scaling
 BL hansens PKDL

Almost symmetrical hypopig. Similar symmetrical hypopig.

patches – hypoaesthesia, patches – but with H/o past
hypohidrosis, nerve fever (s/o past kalaazar) ,
thickening, no scales normal sensations, Normal
nerves, no scales
Past fever with hyperpig

PKDL BL
 Vignette 5
- Dark truncal lesions
Unilateral, brown patch on
shoulder, back, Congenital, blue patch- on
hypertrichosis, acne- onset shoulder, upper back (red
puberty (yellow arrow)- arrow)- NEVUS OF ITO
BECKERS NEVUS
Large brown patches Small perifollicular, brown
on trunk- Child- on trunk, fine scaling
Urticaria pigmentosa (yellow arrow)- P. versicolor
 Vignette 6. Papulosquamous eruptions

RED SLiPS

R: Reiter’s disease
E: Eczema
D: Dermatophytes (Tinea)

S: Secondary syphilis
Li: Lichen planus
P: Psoriasis, Pityriasis rosea
S: Seborrheic dermatitis
 Papulosquamous eruptions
Extensors, itchy
Flexure or extensors,
Psoriasis- Scaly, Red
itchy
Atopic eczema- oozing, Non itchy, acral
lichenification, h/o Secondary syphilis
atopy
Seborrheic areas, itchy
Seborrheic dermatitis-
yellow greasy scales
Annular, itchy
P. Rosea
Flexural, itchy Psoriasis like lesions
Tinea
LP- No scale, Reiters- Thick lesions,
Purple, circinate balanitis,
papules Plantar keratin
Flexural eczema with oozing- Atopic eczema
Flexural, non scaly, Extensor, scaly,
purple papules on papules/plaques-
wrist- LP Psoriasis
Thick keratotic plaques Non itchy, scaly
on sole but with pus plaques on sole, dry-
discharge- Reiters Secondary syphilis
Yellow, greasy scales- Seb. Dermatitis
 Vignette 7. Alopecia

Signs of inflammation,
wrinkling of skin, scaling–
SCARRING ALOPECIA No Signs of inflammation, No
scaling - NON SCARRING
ALOPECIA
Always Patchy
localised Patchy Generalised
localised
 Patchy localised scarring
• Lichen planopilaris
• DLE/ SLE
• T. capitis (Kerion/ Favus)
LP pilaris- Patchy scarring alopecia
(foot print in snow appearance). Scarring areas (red
arrow) , intervening normal hairs (Yellow arrow),
perifollicular blue grey macules (blue arrow)
DLE- Discoid erythematous plaques with thick
scales (blue arrow), peripheral rim of
hyperpigmentation (yellow arrow)
Kerion Favus

Child- Boggy, inflammed Child- Scarring alopecia,

swelling, pus, alopecia Yellow cup shaped
scutulum (red arrow)
 Vignette 7. Alopecia

Signs of inflammation,
wrinkling of skin, scaling–
SCARRING ALOPECIA No Signs of inflammation, No
scaling - NON SCARRING
ALOPECIA
Always Patchy
localised Patchy Generalised
localised
 Patchy Non Scarring
• Alopecia areata (localized)
• Secondary syphilis (moth eaten alopecia)
• Trichotillomania
• T. capitis (Grey patch/ Black dot)
Trichotillomania- Patchy, Incomplete hair
loss, Hairs of varying lengths. Pt may pull
on dominant hand side
 Alopecia areata Grey patch T. Capitis

Patchy, smooth surfaced, complete

hair loss (blue), Sparing of white
Patchy, scaly, itchy alopecia,
hairs (orange arrow), no hairs of
easy pluckability of hairs
varying lengths in the patch
Wrinkled/scarred skin in hair Patchy alopecia but no
loss patch- “Footprint in wrinkling, skin normal under
snow” appearance- LP pilaris hair loss- Alopecia areata
 Diffuse alopecia on vertex-
Wrinkled/scarred skin in hair increased central parting but
loss patch-Prominent no wrinkling, skin normal
follicular prominence-LP under hair loss- Female
pilaris Androgenetic alopecia
 Vignette 7. Alopecia

Signs of inflammation,
wrinkling of skin, scaling–
SCARRING ALOPECIA No Signs of inflammation, No
scaling - NON SCARRING
ALOPECIA
Always Patchy
localised Patchy Generalised
localised
 Diffuse Non Scarring
• Androgenetic alopecia (AGA)
• Alopecia totalis/ universalis
• Telogen effluvium
• Anagen effluvium
• SLE
 Male AGA Female AGA

Hair line recession(Frontal,

bitemporal), vertex loss Hair line maintained, vertex loss
Alopecia totalis Alopecia universalis

Look for complete loss on Look for complete loss all

scalp hairy areas of body
Vignette 8. STD
Primary chancre Donovanosis

Single ulcer- painless,

hard, dirty slough on floor, Painless, red, vascular ulcer,
Dory flop +ve bleeds
Syphilis ulcer
 Secondary syphilis

Rash- faint patches, macules-

Hyperpigmented macules, Difficult to diagnose “the great
scaly papules- Deep imitator”
dermal tenderness +
LGV- Bubo- Groove sign +
Painful- 1st episode
Painless- later episodes
Chancroid

Ipsilateral bubo
 Herpes genitalis
Grouped painful vesicles, ulcers

Grouped
vesicles

Ulcers
Grouped
vesicles
 Pund cells/ Greenblatt cells
Mononuclear cells

Nucleus-eccentric, Donovan Closed safety pin

bodies inside vacuoles
(intracellular)
 Clue cells

Gram stain Wet mount

Gardnerella vaginalis and other anaerobic bacteria

densely in clusters on surfaces of squamous epithelial
cells, giving a granular appearance
 “School of fish”-
extracellular gram negative
in Chancroid
Vignette 9- Blisters
 PV

Oral irregular
Erosions, crusting, painful ulcers
some healing with
hyperpigmentation
PV

Row of
tombstones
SC PF

blister
 SJS/TEN

Hemorrhagic
crust- lip
Targetoid
lesions
 SJS/TEN

Dusky tender macules/patches

(orange arrow) -
Nikolsky +ve (red arrow)
 SSSS PF

Scales-crust, Seborrheic
Scales-crust, Seborrheic
area, Mucosa normal-
area, Mucosa is normal-
but adult,no fever,DIF
but child, fever, DIF -ve
+ve
 Hailey-Hailey disease

Pustules, vesicles in Painful Fissures

flexures
Dilapidated brick wall-
Hailey-Hailey disease
 EBS

Flaccid blisters- raw erosions at

handling site
 EBS

Tense itchy blisters- limb, elderly pt

 Histology of BP

Normal
basal cell

Eosinophils
Subepidermal
blister
 DH

Grouped papulovesicles on elbow

(yellow arrow), scratch marks (red
arrow)
Scratch marks in DH
 DH- Histology

Papillary tip blister

Papillary tip
Neutrophils
 LIGA/ CBDC

Cluster of jewels/ Strings of

pearls appearance
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