Terminology in dermatology

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Dermatological diagnoses often have more than one name. DermNetNZ.org attempts to include the most common names for conditions. The World Health Organisation (WHO) is undertaking a massive task to revise the International Classification of Diseases (ICD) to include preferred terminology for skin conditions, ICD11. Refer to the alpha draft of ICD11 for more information.

Lesion A lesion is any single area of altered skin. It may be solitary or multiple.
Rash A rash is a widespread eruption of lesions.
Dermatosis Dermatosis is another name for for skin disease.

Whan examining the skin, a dermatologist assesses distribution, morphology and arrangement of skin lesions, i.e. their number, size and colour, which sites are involved, their symmetry, shape and arrangement.

The dermatologist will carefully feel individual lesions, noting surface and deep characteristics. Which layer(s) of the skin are involved? If scaly, does the surface flake off easily? If crusted, what is underneath?

Specialised techniques include:

Wood's light (long wave UVA) examination for pigmentary changes and fluorescent infections
Dermoscopy for pigmented lesions to diagnose melanoma

Structure of the skin

The skin is considered to have three parts: the outer epidermis, middle dermis and deep subcutaneous tissue. There is a basement membrane that separates the epidermis from the dermis and acts as a communication channel between the two layers.

Structure of the skin

Images provided by University of Auckland

Epidermis
The epidermis is a complex ‘brick wall’ made of cells called keratinocytes, which produce a protein called keratin. The epidermis also contains pigment cells called melanocytes, which produce melanin, Langerhans cells, which present antigens to the immune system, and Merkel cells, which have a sensory function.

Basal layer: the columnar or rectangular cells at the bottom of the epidermis from which new cells are continuously produced. Scattered melanocytes are normally found in this layer.
Squamous cells: as the keratinocytes mature and move upwards towards the skin surface, they become flat in shape, or squamous (also called spinous or prickle cells). Langherhans cells are found in this layer.
Granular layer: flattened cells filled with dark granules containing keratohyaline protein.
Horny layer: stacks of dead cells without nuclei make up the dry or keratinised stratum corneum. The top layer of cells loosens and falls off.
Desmosomes: the structures that stick adjacent keratinocytes tightly together, rather like cement between bricks.

Epidermal appendages include:

Eccrine glands, which produce sweat
Apocrine glands, scent glands found in armpits and groins
Pilosebaceous structures containing hair and sebaceous glands (oil glands)
Nails

Dermis
The dermis is made up of connective tissue that supports the epidermis, providing nutrients and protecting it. The papillary dermis is the upper portion beneath the epidermis and the lower portion is the reticular dermis.

Collagen: protein fibres arranged in bundles providing strength to the skin.
Elastin: protein making up fibres that allow the skin to stretch
Ground substance: gel containing hyaluronic acid and other polysaccharides.
Fibroblasts: cells that produce collagen, elastin and ground substance.
Nerves: sensory and autonomic fibres with distinct nerve endings for touch, heat, cold, pressure and pain.
Blood vessels: arteries, arterioles, capillaries, venules and veins carrying blood to and from the skin.
Lymphatics: extensive network of thin-walled vessels nourishing and draining the skin.
Arector pili muscles: attached to hair follicles. Contraction results in goose bumps.
Cellular infiltrations: immune cells around blood vessels, and recruited in great numbers to heal wounds and fight infection. Many skin diseases are characterised by specific patterns of these cells.

Subcutaneous tissue
The subcutaneous tissue, also called subcutis, is made up of adipose cells or lipocytes (fat cells). These are surrounded by connective tissue, blood vessels and nerves.

Distribution

Distribution refers to how the skin lesions are scattered or spread out. Skin lesions may be isolated (solitary or single) or multiple. The localisation of multiple lesions in certain regions helps diagnosis, as skin diseases tend to have characteristic distributions. What is the extent of the eruption and its pattern?

Acral
Affects distal portions of limbs (hand, foot) and head (ears, nose).

Blaschko's lines
Following a roughly linear, segmental pattern described by Blaschko and thought to be indicative of somatic mosaicism.

Dermatomal
Corresponding with nerve root distribution.

Extensor
Involving extensor surfaces of limbs. Contrast with flexor surfaces.

Flexural
Involving skin flexures (body folds); also known as intertriginous.

Follicular
Individual lesions arise from hair follicles. These may be grouped into confluent plaques.

Generalised
Universal distribution: may be mild or severe, scattered or diffuse

Herpetiform
Grouped umbilicated vesicles, as arise in Herpes simplex and Herpes zoster infections.

Koebnerised
Arising in a wound or scar. The Koebner phenomenon refers to the tendency of several skin conditions to affect areas subjected to injury.

Photosensitive
Favouring sun exposed areas. Does not affect skin that is always covered by clothing.

Head & neck: spares eyelids, depth of wrinkles & furrows, areas shadowed by hair, nose & chin. Typically involves V of neck.
Backs of hands: spares finger webs. More severe on proximal than distal phalanges.
Forearms: extensor rather than flexor.
Feet: dorsal surface, sparing areas covered by footwear.
Lower legs: may affect extensor and/or flexor surfaces
Trunk: rarely affected

Pressure areas
Affecting areas regularly prone to injury from pressure at rest.

Tops of the ears when sleeping
Buttocks when sitting
Heels when lying

Seborrhoeic
The areas generally affected by seborrhoeic dermatitis, with a tendency to oily skin (seborrhoea). Scalp, behind ears, eyebrows, nasolabial folds, sternum and interscapular.

Symmetrical
In the same regions, the left side is affected in a similar way to the right side.

Truncal
Favours trunk and rarely affects limbs.

Unilateral
Wholly or predominantly on one side of the affected region.

Configuration of Lesions

Configuration refers to the shape or outline of the skin lesions. Skin lesions are often grouped together. The pattern or shape may help in diagnosis as many skin conditions have characteristic configuration.

Nummular lesion Round (coin-shaped) lesions. Also known as discoid.
Linear lesion A linear shape to a lesion often occurs for some external reason such as scratching. Also striate.
Target lesion Concentric rings like a dartboard. Also known as iris lesion.
Gyrate rash A rash that appears to be whirling in a circle.
Annular Lesions grouped in a circle.

Colour

Descriptive terms used to describe skin colour include:

Carotenaemia
Excessive circulating beta-carotene (vitamin a precursor derived from yellow/orange coloured vegetables and fruit) results in yellow/orange skin colouration. Tends to be pronounced on palms and soles. Does not affect cornea.

Hyperpigmentation
Hypermelanosis or haemosiderin deposits result in skin colour that is darker than normal.

Hypopigmentation
Loss of melanin results in skin colour that is paler than normal but not completely white.

Leukoderma
White skin. Also known as achromia.

Infarcts
Infarcts are black areas of necrotic tissue due to interrupted blood supply.

Jaundice
Excessive circulating bilirubin results in yellow/green skin colour, prominent in cornea.

Erythema
Red skin due to increased blood supply and blanch with pressure (diascopy).

Erythroderma The skin condition affects the whole body or nearly the whole body, which is red all over.
Telangiectasia Telangiectasia is the name given to prominent cutaneous blood vessels.
Purpura Purpura is bleeding into the skin. This may be as petechiae (small red, purple or brown spots) or ecchymoses (bruises). Purpura does not blanch with pressure (diascopy).

Morphology

Morphology is the form or structure of an individual skin lesion.

Skin lesions may be flat, elevated above the plane of the skin or depressed below the plane of the skin.
They may be skin coloured or red, pink, violaceous, brown, black, grey, blue, orange, yellow.
Consistency may be soft, firm, hard, fluctuant or sclerosed (scarred or board-like).
The lesions may be hotter or cooler than surrounding skin.
They may be mobile or immobile.

Macule A macule is an area of colour change less than 1.5 cm diameter. The surface is smooth.
Patch A patch refers to a large area of colour change, with smooth surface.
Papule Papules are small palpable lesions. The usual definition is that they are less than 0.5 cm diameter, although some authors allow up to 1.5 cm. They are raised above the skin surface, and may be solitary or multiple.
Papules may be: Acuminate (pointed) Dome-shaped (rounded) Filiform (thread-like) Flat-topped Oval or round Pedunculated (with a stalk) Sessile (without a stalk) Umbilicated (with a central depression) Verrucous (warty)
Nodule A nodule is an enlargement of a papule in three dimensions (height, width, length). It is a solid lesion.
Cyst A cyst is a papule or nodule that contains fluid so is fluctuant.
Plaque A plaque is a palpable flat lesion greater than 0.5 cm diameter. Most plaques are elevated, but a plaque can also be a thickened area without being visibly raised above the skin surface. They may have well-defined or ill-defined borders.

Plaques may be:

Annular (ring shaped)
Arcuate (half-moon)
Polygonal (varied non-geometric shape)
Polymorphic (varied shape)
Serpiginous (in the shape of a snake)
Poikilodermatous (variegated appearance, usually mixed pallor, telangiectasia & pigmentation)

Vesicle Vesicles are small fluid-filled blisters less than 0.5cm diameter. They may be single or multiple.
Pustule A pustule is a purulent vesicle. It is filled with neutrophils, and may be white, or yellow. Not all pustules are infected.
Bulla A bulla is a large fluid-filled blister. It may be a single compartment or multiloculated.
Abscess An abscess is a localised collection of pus.
Weal A wheal is an oedematous papule or plaque caused by swelling in the dermis. Wealing often indicates urticaria.

Skin surface

The skin surface of a skin lesion may be normal or smooth because the pathological process is below the surface, either dermal or subcutaneous. Surface changes indicate epidermal changes are present.

Scaling
Scaling or hyperkeratosisis an increase in the dead cells on the surface of the skin (stratum corneum).

Descriptive terms for scale include:

Desquamation (skin coming off in scales)
Psoriasiform (large white or silver flakes)
Pityriasiform (branny powdery scale)
Lichenoid (apparent scale is tightly adherent to skin surface)
Keratotic (horny scale)
Exfoliation (peeling skin)
Maceration (moist peeling skin)
Verrucous (warty)

Psoriasiform scale	Pityriasiform scale
Exfoliation	Verrucous scale

Secondary changes

Lichenification Lichenification is caused by chronic rubbing, which results in palpably thickened skin with increased skin markings and lichenoid scale. It occurs in chronic atopic eczema and lichen simplex.
Crusting Crust occurs when plasma exudes through an eroded epidermis. It is rough on the surface and is yellow or brown in colour. Bloody crust appears red, purple or black.
Dystrophy Dystrophy refers to degeneration or abnormal formation of the skin. It is often used to refer to nail diseases.
Excoriation An excoriation is a scratch mark. It may be linear or a picked scratch (prurigo). Excoriations may occur in the absence of a primary dermatosis.
Erosion Erosion is caused by loss of the surface of a skin lesion; it is a shallow moist or crusted lesion.
Fissure A fissure is a thin crack within epidermis or epithelium, and is due to excessive dryness.
Fungating Refers to a large malignant tumour that is erupting like a mushroom or fungus.
Granulation tissue Granulation tissue is a made of a mass of new capillaries and fibrous tissue in a healing wound.
Ulcer An ulcer is full thickness loss of epidermis or epithelium. It may be covered with a dark-coloured crust called an eschar.
Granuloma A granuloma is a histological (pathological) term refering to chronic inflammation in which there are several types of inflammatory cells including giant cells. Granulomas form in response to foreign bodies, certain infections (tuberculosis, leprosy) and inflammatory skin diseases (granuloma annulare, granuloma faciale, sarcoidosis).
Hypertrophy Some component of the skin such as a scar is enlarged or has grown excessively. The opposite is atrophy or thinned skin.

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