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Short Note
Differentiating Red From Red: A guide to understanding Dermatological lesions
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Submitted:
29 December 2023
Posted:
05 January 2024
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Abstract
Diagnosing skin lesions can be a challenging task. Dermatologic lesions are hard to differentiate especially for an untrained eye. However, carefully analyzing every aspect of the lesion can help clinicians reach an accurate diagnosis. If diagnosed correctly with the naked eye, many lesions can be treated without the need for further histopathology or investigations. Those aspects include morphology, color, distribution, configuration and arrangement, texture and consistency, and any evolutions or changes within the lesion. Clinicians must also contextualize those lesions into the patient’s history and overall systemic symptoms and signs. Risk factors should be taken into consideration and whether there are evolutionary changes in the lesions. Clinicians should also look for patterns as they might be the key to diagnosis. If definitive diagnosis is still not reached, biopsy, dermatoscopy, cultures, skin scrapings, patch testing, blood tests, and imaging studies may be necessary for confirmation. Integrating these methods with clinical judgment and patient history significantly enhances the accuracy of diagnosis in dermatology. Treatment for dermatologic lesions varies depending on the underlying cause.
Keywords:
Subject: Medicine and Pharmacology - Dermatology
Main body:-
Dermatological lesions are one of the toughest to differentiate and to an untrained eye, all lesion might look the same. It becomes important to understand the lesion and the cause behind it so it can be treated and that too without the help of histopathology or other imaging and just by naked eye.
Lesion Morphology:
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- Macules and Patches: These are flat lesions. Macules are smaller than 1 cm (freckles or petechiae), while patches are larger (vitiligo or eczema).
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- Papules: Small, solid, raised lesions less than 1 cm (acne or mole).
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- Plaques: Large, raised, flat-topped lesions over 1 cm (psoriasis plaques or lichen planus).
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- Nodules: Solid, raised lesions, larger and deeper than papules (lipomas or dermatofibromas).
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- Tumors: Abnormal masses or growths, can be benign or malignant (basal cell carcinoma or melanoma).
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Vesicles and Bullae: Fluid-filled lesions. Vesicles are smaller (herpes simplex), while bullae are larger (pemphigus vulgaris).
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- Pustules: Pus-filled lesions (acne pustules).[1]
Lesion Color:
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- Erythematous: Redness due to inflammation (rosacea or erythema multiforme).
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- Pigmented: Brown or black lesions (moles or melanomas).
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- Hypopigmented: Loss of skin color (vitiligo).
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- Depigmented: White patches (pityriasis alba or tinea versicolor).[2]
Lesion Distribution:
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- Localized: Limited to a specific area or region.
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- Generalized: Spread over a larger body surface.
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- Symmetric: Equal distribution on both sides of the body.
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- Asymmetric: Unequal distribution.[3]
Lesion Configuration and Arrangement:
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- Discrete: Separate lesions.
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- Confluent: Merged lesions forming larger areas.
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- Linear: Lesions in a line (contact dermatitis).
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- Annular: Ring-shaped (ringworm or granuloma annulare).[4]
Texture and Consistency:
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- Lesions can be smooth, scaly, rough, or have a specific texture (like warts or lichenification).[5]
Evolution and Changes:
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- Note any changes in size, shape, color, or symptoms over time. Some lesions may evolve or show characteristic changes, aiding in diagnosis (e.g., changing moles in melanoma).[6]
Symptoms and Signs:
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- Itching, pain, tenderness, warmth, discharge, or associated systemic symptoms (fever, malaise) can provide diagnostic clues.[7]
Patient History:
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- Onset, duration, progression, triggers, prior treatments, and medical history are crucial. Specific questions regarding exposure to allergens, irritants, or infectious agents can be vital.[8]
Risk Factors and Context:
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- Consider environmental exposures, lifestyle, family history, occupation, and travel history, which might be relevant to the diagnosis.[9]
Diagnostic Tests and Procedures:
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Biopsy, dermatoscopy, cultures, skin scrapings, patch testing, blood tests, and imaging studies (such as ultrasound or MRI) may be necessary for confirmation, especially in complex or challenging cases.
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- Histopathological Features: Detailed microscopic examination of a skin biopsy can provide invaluable information. Histopathology helps identify cellular changes, inflammation patterns, presence of specific cells (like melanocytes, lymphocytes), and tissue alterations, aiding in pinpointing the underlying cause.[10]
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- Immunohistochemistry: This specialized technique uses antibodies to detect specific proteins within tissues, assisting in differentiating between various lesions, especially in cases like tumors or inflammatory conditions where specific markers may be present or absent.[11]
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- Dermoscopy: This non-invasive technique involves using a dermatoscope to examine skin lesions under magnification. It reveals specific structures and colors within the lesion (like pigment network, vascular patterns, and specific colors) that may not be visible to the naked eye, aiding in distinguishing between benign and malignant lesions.[12]
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- Clinical Patterns: Certain dermatological conditions exhibit distinctive patterns. For instance, psoriasis typically presents with well-defined erythematous plaques with silvery scales, while eczema may show areas of erythema, edema, and crusting with a predilection for flexural areas.[13]
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- Molecular Testing: In cases of suspected genetic skin disorders or certain cancers, molecular testing (such as PCR, and DNA sequencing) can be instrumental in confirming diagnoses. This is particularly important in diagnosing conditions like melanoma or genodermatoses.[14]
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- Specialized Imaging: Techniques like ultrasound, MRI, or CT scans might be utilized in specific cases to evaluate the extent of lesions, especially when deeper tissue involvement is suspected, as in the case of some inflammatory or neoplastic conditions.[15]
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- Pattern Recognition Algorithms: Emerging technologies use AI-based algorithms to analyze extensive databases of skin lesions, assisting dermatologists in making more accurate diagnoses based on lesion patterns and characteristics. [16]
The integration of these advanced methods with clinical judgment and patient history significantly enhances the accuracy of diagnosis in dermatology. It's essential to consider these multifaceted approaches to accurately differentiate between various dermatological lesions, especially when dealing with complex or challenging cases. Anyhow It is important for a dermatologist or any medical doctor to be able to recognize the lesions at least with the naked eye and diagnostic tests can be used as an adjuvant help along with scopes.
Conclusions:
It is important for dermatologists to supplement their understanding of skin conditions with careful and inclusive skin examination as not to miss on any important findings crucial to diagnosis. The patient’s history together with systemic symptoms and signs are also equally important. Doing so will narrow the scope of potential diagnoses and make it easier to reach a definitive diagnosis.
Ethical Statement
Being a Short note, there were no ethical issues and IRB permission is not required.
Funding and Sponsorship
"None of the authors have a financial interest in any of the products, devices, or drugs mentioned in this manuscript."
Conflicts of interest
The authors declare no conflict of interest.
References
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- S. PLENSDORF, M. LIVIERATOS, and N. DADA, “Pigmentation Disorders: Diagnosis and Management,” Am Fam Physician, vol. 96, no. 12, pp. 797–804, Dec. 2017, Accessed: Dec. 28, 2023. [Online]. Available: https://www.aafp.org/pubs/afp/issues/2017/1215/p797.html.
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- T. Ferringer, “Skin,” Handbook of Practical Immunohistochemistry: Frequently Asked Questions, pp. 921–954, Jan. 1990. [CrossRef]
- “Description of Skin Lesions - Dermatologic Disorders - MSD Manual Professional Edition.” Accessed: Dec. 28, 2023. [Online]. Available: https://www.msdmanuals.com/professional/dermatologicdisorders/ approach-to-the-dermatologic-patient/description-of-skin-lesions.
- J. Dinnes et al., “Visual inspection for diagnosing cutaneous melanoma in adults,” Cochrane Database Syst Rev, vol. 2018, no. 12, Dec. 2018. [CrossRef]
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- G. Novak-Bilić, M. Vučić, I. Japundžić, J. Meštrović-štefekov, S. Stanić-Duktaj, and L. Lugović-Mihić, “IRRITANT AND ALLERGIC CONTACT DERMATITIS – SKIN LESION CHARACTERISTICS,” Acta Clin Croat, vol. 57, no. 4, p. 713, 2018. [CrossRef]
- “Contact dermatitis and urticaria from environmental exposures. Agency for Toxic Substances and Disease Registry.,” Am Fam Physician, vol. 48, no. 5, pp. 773–780, Oct. 1993.
- “RACGP - Skin biopsy in the diagnosis of inflammatory skin disease.” Accessed: Dec. 28, 2023. [Online]. Available: https://www.racgp.org.au/afp/2017/may/skin-biopsy-in-the-diagnosis-of-inflammatory-skin.
- D. Chatterjee and R. Bhattacharjee, “Immunohistochemistry in Dermatopathology and its Relevance in Clinical Practice,” Indian Dermatol Online J, vol. 9, no. 4, p. 234, 2018. [CrossRef]
- X. Wu, M. A. Marchetti, and A. A. Marghoob, “Dermoscopy: not just for dermatologists,” Melanoma Manag, vol. 2, no. 1, p. 63, Feb. 2015. [CrossRef]
- C. M. Chuong et al., “What is the biological basis of pattern formation of skin lesions?,” Exp Dermatol, vol. 15, no. 7, p. 547, 2006. [CrossRef]
- S. Heneidi, J. A. Golden, and E. Vail, “Molecular Testing for Diagnostics, Prognostication, and Treatment Stratification in Cancers,” Cancer J, vol. 29, no. 1, pp. 3–8, Jan. 2023. [CrossRef]
- A. Mandava, P. Ravuri, and R. Konathan, “High-resolution ultrasound imaging of cutaneous lesions,” Indian J Radiol Imaging, vol. 23, no. 3, p. 269, 2013. [CrossRef]
- Z. Li, K. C. Koban, T. L. Schenck, R. E. Giunta, Q. Li, and Y. Sun, “Artificial Intelligence in Dermatology Image Analysis: Current Developments and Future Trends,” J Clin Med, vol. 11, no. 22, Nov. 2022. [CrossRef]
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