Blisters
Dr Saurabh Jindal
Navigate through
the maze of
images with
flowcharts
Outline
• Sure shot topics with Mnemonics
• Blisters
• Papulosquamous lesions
• White lesions
• Dark lesions
• Leprosy
• Alopecia
• STD
Blistering disorders
• The 3- line magic
Quiz
• Scale/crust presentation
• Seborrheic area
• No mucosal involvement, Nikolsky positive, DIF +ve
Very flaccid blister Raw areas
• Scales-crust
• Seborrheic area
• Mucosa is normal
• DIF +ve
Quiz
• Scale/crust presentation/Seborrheic area
• No mucosal involvement, Nikolsky positive
• Add Fever, Hypopyon sign, DIF Negative
Hypopyon sign
Very flaccid blister Raw areas
• Scales-crust
• Seborrheic area
• Mucosa is normal
• Fever, Hypopyon sign
• DIF -ve
Quiz
• Painful erosions all over the body
• Mucosal involvement
• Nikolsky +ve, DIF +ve
Less flaccid blister
Oral irregular painful ulcers
Erosions, crusting, some healing
with hyperpigmentation
Row of tombstones
SC
blister
SB
Quiz
Causes for Nikolsky Sign
• S/o Epidermal Acantholysis
• To differentiate intraepidermal blisters from subepidermal blisters.
Quiz
• Drug induced painful erosions , Targetoid lesions, Skin necrosis
• Mucosal involvement
• Nikolsky +ve, DIF -ve
Epidermal necrolysis
Hemorrhagic crust- lip
Targetoid lesions
Dusky tender macules/patches (orange arrow) -
Nikolsky +ve (red arrow)
Quiz
• Congenital trauma induced blisters
• DIF –ve
• Genetic deficiency of Keratin/Laminin/Collagen
Flaccid blisters- raw erosions at handling site
EBD- tense
blisters at
handling site
EBD- Heals with
scarring
Quiz
• Elderly
• Tense itchy blister on red skin
• Nikolsky Neg, BSS positive, DIF + (Anti Bp2 > Anti Bp1- IgG)
Hemidesmosome
BP
Tense itchy blisters- limb, elderly pt
Tense itchy blisters- limb, elderly pt
Histology of BP
Normal
basal cell
Eosinophils
Subepidermal
blister
Quiz
• Grouped, Tense vesicles
• Severe itch and scratch
• Gut issues
Grouped papulovesicles on elbow (yellow arrow),
scratch marks (red arrow)
Scratch marks in DH
Papillary
tip blister
Papillary tip
Neutrophils
Brick Cement Desmosome Hemidesmosome Diagnosis
Intact Intact Broken Intact Pemphigus
(Acantholysis) • Subcorneal Desmosome
broken (PF)
• Suprabasal Desmosome
broken (PV)
SSSS
Subcorneal Desmosome
broken
Intact Broken Intact` Intact Eczema
Broken Intact Intact Intact EBS
Intact Intact Intact Broken BP
Acantholysis- Tzanck smear (Giemsa)
Primary
Secondary
• Pemphigus
• Herpes
• SSSS
• Darier
• Hailey
Hailey disease
Flow chart
Papulosquamous eruptions
• The 3- line magic
Quiz
• Oozing, Itch, Scaling, blisters
• Flexure (Adult), Extensor (Child)
• Asthma/ rhinitis/ Recurrent URTI
Flexural eczema with oozing
M/c =Nickel
Dx- Patch test
Quiz
• Non scaly
• Lichenoid
• Flexure
Flexural, non scaly, purple
papules on wrist
• 5 P (Purple/Polygonal/Pruritic/Plain
topped/Papules)
• Oral LP-White lacy
• Nail LP- Pterygium- classical, longitudinal
ridging/Thinning/20 Nail dystrophy/Tenting
• LP Pilaris- Scarring/Footprint in snow
• LP pigmentosus- Sun exposed pigmentation
Histology Of LP
Oral LP-
Wickham’s striae
Criss cross- lacy
White lesions in Mouth
• Lacy, • Uniform plaques • Uniform
reticular, • h/o imm.suppr plaques
dental • h/o DM • Can’t be
amalgam • Pseudomembrane
scrapped
near by
Uniform plaque, not
Uniform plaques, scrapable scrappable-
INI CET Nov 23
An immunocompromised individual presents with a corrugated white
lesion on the side of the tongue which does not wipe off. The cause
would be:
A. EBV
B. HSV 1
C. Candida
D. HHV 8
Quiz
• Scaly
• Red
• Extensor
Extensor, scaly,
papules/plaques- Psoriasis
• Auspitz sign + (neg. in Pustular/Inverse)
• Guttate- Small lesions- Rx Antibiotics
• Erythrodermic- > 90% - Rx
Methotrexate/Cyclosporine/Biologicals
• Arthritis- DIP involved
• Pustular (lakes of pus)- Von Zumbusch- rx
Acitretin/ Impetigo herpetiformis- rx
steroids
• Inverse- On flexures
• Sebopsoriasis
• Complication- Metabolic syndrome
Histology of Ps
Yellow, greasy scales
Quiz
• Prior Urethritis- m/c Chlamydia (STD)/ Diarrhoea
• Arthritis- Uveitis
• Plantar hyperkeratosis/Circinate balanitis
Thick keratotic plaques
on sole but with pus
discharge- Reiters
Collarette scales
Flow chart
Papulosquamous eruptions
Extensors, itchy
Flexure or extensors,
Psoriasis- Scaly, Red
itchy
Atopic eczema- oozing, Non itchy, acral, scaly
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
Vaginal candidiasis—
Gram-stain showing Gram-positive budding yeasts
Bacterial vaginosis—A normal vaginal
Wet mount of Trichomoniasis— epithelial cell (red arrow) and an epithelial
cell with its exterior covered by bacteria
Plenty of
giving a roughened, stippled appearance
trichomonas on smear known as a “clue cell” (yellow arrow)
Hypopigmented lesions -Face
Flow chart
Hypopigmented lesions -Face
Indeterminate hansens P. alba
Normal sensations, normal Normal sensations, normal
sweating, atrophy+, from endemic sweating, No atrophy, Fine
areas scaling, h/o atopy+
Depigmented- face
Depigmented
Patterned No Pattern
• Check for hair • Irregular margins
margins • Leucotrichia
• Bindi area • h/o underlying
• Moustache autoimmunity
• Contact leucoderma • Vitiligo
Flow chart
Depigmented- face
Depigmented
Patterned No Pattern
• Check for hair • Irregular margins
margins • Leucotrichia
• Bindi area • h/o underlying
• Moustache autoimmunity
Patterned patch- due to PPD in Patterned patch- due to
hair dye kumkum
White lesions at birth
Albinism
Diffuse depigm. Skin, hair
since birth
Piebaldism
N. depigmentosus-
Unilateral ,
congenital
Flow chart
Hypopigmented lesions- trunk
Small hypopig. macules Large hypopig. Patches
Scratch sign +
Almost symmetrical hypopig. Similar symmetrical hypopig.
Patches – hypoaesthesia, patches – but with H/o past
hypohidrosis fever , normal sensations
Dark lesions
Level of colour Clinical colour Disease
a) Basal epidermis/ DEJ Brown • Junctional nevus/ compound nevus
• Melasma, Chik sign
• Mastocytosis
• Brown P. versicolor
• Becker’s nevus
Junctional melanocytic nevus
Flat brown macule- Junctional AMN
Compound melanocytic nevus
Elevated brown papule- Compound AMN
Brown patches-cheek, nose.
Photosensitivity +
Level of colour Clinical colour Disease
b) Superficial dermis Purple/ •Lichen planus
Violaceous •Fixed drug eruption
Level of colour Clinical colour Disease
c) Deep dermis Blue/Grey •Mongolian spot
•Nevus of Ota
•Nevus of ito
Congenital, blue patch- on
Congenital, blue patch,
shoulder, upper back-
lumbosacral area
NEVUS OF ITO
Leprosy
When a student sees Leprosy question !!
TT LL
• Well defined border • ill Defined border
• Hypopigmentation • Erythematous
• Sensory loss/Sweat loss • Normal sensation/sweat
• No nodules • Nodules
• Granuloma • Foam cells
• SSS Negative • SSS Positive
• No symmetrical lesions • Symmetrical lesions
Lepra cells-
________ stain
LL
• Epistaxis
• Ear lobe infiltration
• Gynecomastia
• Peripheral neuropathy/Trophic ulcers
• Lagophthalmos/Exposure keratitis
• Painless nodules
• Madarosis/Saddle nose/Nasal septal perforation
Inflammation of existing Inflammation of new nodules on
lesions extremities and face
No fever Fever
Neuritis may coexist Arthritis, Orchitis, Hepatitis, Uveitis,
glomerulonephritis, lymphadenopathy
may coexist
ENL
Alopecia
• The 3- line magic
Quiz
• Thinning/Miniaturisation
• Patterned, Non scarring alopecia
• Recession (Male), Widening of parting (Female)
Hair line recession(Frontal,
bitemporal), vertex loss Hair line maintained, vertex loss
Quiz
• Incomplete non scarring alopecia
• Varying lengths hair, female
• Dominant hand side
Quiz
• Scarring alopecia
• Patchy- Footprint in snow
• Autoimmune
Quiz
• Child with easily pluckable
• Woods lamp positive
• Boggy/Broken hairs/Scaly
Quiz
• Complete alopecia – non scarring
• Sparing of white hairs
• Exclamation hairs/ Regular nail pitting
Quiz
• Alopecia in sun exposed areas
• Scaly, red centre, periphery hyperpigmented
• Scarring
Quiz
• Non scarring alopecia
• Diffuse alopecia (No pattern)
• Past fever/Labor / chemotherapy
Alopecia
Flow chart
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
Alopecia
Signs of inflammation,
wrinkling of skin, scaling–
SCARRING ALOPECIA
Always Patchy
localised
Alopecia
No Signs of inflammation, No
scaling - NON SCARRING
ALOPECIA
Patchy
localised
Alopecia
No Signs of inflammation, No
scaling - NON SCARRING
ALOPECIA
Generalised
STD
• The 3- line magic
Quiz
• Single ulcer
• Hard/Painless
• No bleed
Quiz
• Non itchy rash
• Moist perianal lesions
• Mucous patch. Moth eaten alopecia
Rash- faint patches, macules-
Hyperpigmented macules, Difficult to diagnose “the great
scaly papules imitator”
EARLY SYPHILIS Primary
( < 2 yrs) Secondary
Early latent
LATE SYPHILIS Late latent
( > 2 yrs) Tertiary
Quiz
• Multiple ulcers
• Soft/Painful/Kissing ulcers
• No bleed + Unilateral bubo
Ipsilateral bubo
Rx:
Azithromycin 1 gm stat
or
Inj. Ceftriaxone 250 mg im stat
Quiz
• Single ulcer
• Bleeds/Vascular
• No bubo (granuloma in inguinal region)
Painless, red, vascular ulcer,
bleeds
Quiz
• Unnoticed painless ulcer
• B/L Bubo
• Lymph blockage
Quiz
• Grouped painful vesicles/ulcers
• Recurrent
• No partner treatment
Grouped
vesicles
Ulcers
Grouped
vesicles
Microscopy in STD
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
Vaginal candidiasis—
Gram-stain showing Gram-positive budding yeasts
Bacterial vaginosis—A normal vaginal
Wet mount of Trichomoniasis— epithelial cell (red arrow) and an epithelial
cell with its exterior covered by bacteria
Plenty of
giving a roughened, stippled appearance
trichomonas on smear known as a “clue cell” (yellow arrow)
Grey for Gonorrhea
Indication:
Cefixime + Azithromycin
(Covers Gono + Chlamydia)
Green frothy discharge
Indication:
Secnidazole + Fluconazole
(Covers Candida,
Trichomonas, Bacterial
vaginosis)
White kit- Penicillin injection is very white
like milk
Indication:
Benzathine Pn + Azithromycin
(Covers syphilis and chancroid)
Blue kit-
Indication:
Doxy + Azithromycin
(Covers syphilis and chancroid)
(Bubonic
Plague)
Indication:
Doxy + Azithromycin
( Covers Chancroid and LGV)
Red kit- red is color for danger
Indication:
Has Aciclovir
(Cover herpes genitalis)
Yellow kit- yellow is color
Ovarianfor Pus
abscess
Ovarian abscess
Indication:
Doxy+ Cefixime + Metronidazole
(Cover Gono+ Bacteria+ Anerobes)
STD Flow chart
Painful
In the next few days days, fear will be
your biggest enemy
- Fear of failing
- Fear of ‘What if I don’t make it’
- Fear of losing respect
- Fear of losing your dreams
# GET BACK UP
Each day for the few weeks, you will create your future.
Expect a Roller -coster in the next 90 days
