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Without treatment, a third of the infected persons may develop a late stage of Syphilis after several years. Any organ may be affected by chronic inflammation and resulting damages, leading to disablement or even death.
On the skin, bizarrely arranged nodes and destructive tumor-like ulcerations occur, which leave behind scars.
Damage of the spinal cord with loss of tactile sensation in the feet. Because of the lack of sensation of pain, pressure sores may form without being noticed.
An infection of the mother during pregnancy often leads to a stillbirth. If the mother was infected before the beginning of the pregnancy, the progress of the disease is less harmful, but still causes inflammation and permanent growth retardation in the child.
Various wart viruses can be sexually transmitted, and can proliferate on the mucosae. The most common ones are Condylomata acuminata.
The small papules may grow and become tumorous. Very rarely, they evolve into skin cancer.
Catalogue p. 41
The infection of the urethra with chlamydia is the most common STI worldwide. A white-yellowish discharge is accompanied by burning pain during urination. An infection with gonococci (gonorrhoea, clap) will progress very similarly. A chronic infection can result in sterility.
Peripartum transmission onto the child through smear infection enhances the risk of blindness as a result of the conjunctivitis.
In Europe, the infection with the bacterium Haeomphilus ducrey has become very rare. Typically, a painful, frayed, oval ulceration in the genital region occurs, accompanied by swelling of the surrounding lymph nodes.
Additional moulages on STIs in showcase 47, right side.
Catalogue p. 29
Wheals are the typical skin change of the urticaria. They appear within a few minutes and stay for no longer than several hours in the same spot. Urticaria is quite common. In up to 80% of the cases, the etiological factors are unknown.
Whenever an immediate-type hypersensitivity is suspected (e.g. hay fever), allergens can be tested directly on the skin. In a immediate-type allergy, this test results in a wheal. In Zurich, tests on patients with hay fever were conducted as early as 1940, laying the basis for today's standardised routine tests.
Catalogue p. 30
Erythema multiforme with the characteristic rosette-shaped cockades. The mild form is usually an allergic reaction to a herpes virus infection.
If the EEM is the result of drug intolerance, the progression may be severe with blisters on the entire body = Stevens-Johnson Syndrome.
Catalogue p. 31
The toxic epidermal necrolysis is the worst outcome of the Stevens-Johnson Syndrome caused by drug intolerance, with large blisters forming painful raw areas. Despite best possible treatment, today's mortality rate still lies by roughly 30%!
The clinical picture of the TEN equals the one of the Staphylococcal Scalded Skin Syndrome (SSSS), caused by the staphylococcal toxin (to compare see Moulage 606 in showcase 26).
Catalogue p. 32
Medication can cause allergic or toxic intolerance reactions with eczema.
If painful, greyish spots and blisters occur with an involvement of the mucosa, there is a high risk of a TEN.
In case of a fixed toxic drug eruption, the spots and blisters always rise at the same locations on the body, whenever the triggering drug is taken.
Additional moulages on drug intolerances in showcase 48.
Catalogue p. 33
The painful nodes usually appear on the shinbone as an attendant phenomenon of inflammatory diseases, after infections or as allergic reaction to drugs. Over time, the nodes turn blueish-yellowish and tend to look like bruises.
Catalogue p. 33
Eczema are toxic or allergic intolerance reactions of the skin and occur in a quarter of all patients with skin diseases. They are not contagious.
Red skin and small blisters are typical for a fresh (acute) eczema. Later on, the skin desquamates and thickens.
Because of varying aetiologies, one can distinguish between atopic, nummular, seborrheic, toxic and allergic (contact) eczema.
Catalogue p. 34
Roughly 20% of the population has a predisposition to skin allergy and mucosal reactions (atopy, atopic diathesis). There is a linkage to the disposition of eczema. However, there usually is no direct connection between reported allergies and eczema.
In infants, heavily itching eczema appear on the cheeks and the entire face. In particular, the crusts on the hairy head resemble burned milk, from which the term "milk crust" originates. In half of the cases in infants, the disease will heal completely by the age of two. However, the disposition remains.
Typical image of a distinctive chronic atopic eczema.
A common localisation of the atopic eczema in adults: knee pit (popliteal fossa) and elbow pit (cubital fossa), wrists, neck, forehead and eyelids. The moulage illustrates the clearly visible thickening of the skin (lichenification) as a result of the chronic inflammation.
Common localisation of the atopic eczema in the elbow pit (cubital fossa).
Additional moulages on atopic eczema in showcase 49 below and right.
Catalogue p. 36
Our skin gets into contact with countless substances. If these are neither chemically nor physically aggressive, no reactions are triggered. However, certain substances – harmless though they may be - can trigger an eczema at some point in time, depending on the individual predisposition. A sensitised person's skin reacts within several hours up to two days (so-called late phase reaction).
The most common contact allergens include ubiquitous molecules like nickel (fashion jewellery), chromium (cement; tanning agent in leather), fragrances (e.g. Balsam of Peru) and wool wax alcohols (skin care products).
If an allergic contact dermatitis is suspected, suspicious substances can be tested with the help of an epicutaneous test, the so-called patch test (see also showcase 2).
In particular, vegetable and animal proteins can lead to contact eczema, like in this patient, who used udder balm made of different plant extracts as treatment for his dry skin.
Allergic late phase reaction to a shampoo ingredient.
Contact allergies trigger an eczema at the test spot. The toxic eczema stays precisely limited to the contact site (soft soap, left) the allergic immune reaction on the other hand spreads to the adjacent skin (nickel sulphate, right).
Catalogue p. 35
The skin protects the body from aggressive substances using a protective coating consisting of corneocytes, acidic conditions and a greasy film. If this protective coating is damaged or stressed, an itching eczema appears.
Irritant contact eczema with sharp limitation to the damaged skin.
In the past, many colours were dissolved in turpentine oil. The turpentine eczema was a typical occupational disease of the painter. Chronic stress on the hands with water and cleaning agents triggers a toxic eczema. The damaged protective coat and the inflammation enhance the risk of the development of the allergic contact eczema.
The most common damage to the skin's protective coat is caused by dehydration. Particularly at an older age or through frequent washing, the skin gets dry and chapped. Along those fissures, the eczema rises together with an annoying itch. The image resembles the craquelure of antique vases (Eczema craquelée).
Catalogue p. 35
The cause of the nummular eczema is still unknown. For a long time, bacteria were thought to cause allergic reactions, thus the name "microbial eczema".
Catalogue p. 37
The predisposition to mild seborrheic eczema with dandruff and a disposition to greasy skin is prevalent to such an extent that people usually perceive it as normal. Usually, special shampoos serve as an adequate treatment. Although the seborrheic eczema cannot be healed completely that way, it can be controlled very well.
Typically affected locations are the scalp, the auditory canal, eye brows, the nasolabial groove and the sweat channels front and back (in the middle of the chest and the back).
Additional moulages on allergic contact dermatitis in showcase 49, left side.
Catalogue p. 43
Autoimmune dermatosis are chronic inflammatory diseases characterised by reactions of the patient’s immune system against structures of the skin.
Catalogue p. 43
The term Lupus erythematosus (LE) sums up various autoimmune inflammations with a similar clinical picture and laboratory findings. However, they differ in symptoms and prognosis.
Chronic discoid Lupus erythematosus (CDLE)
CDLE often manifests itself on the face by discoid, sharply bordered red plaques.
Sunlight will worsen a CDLE, especially the very inflammable kind of Lupus tumidus with tumor-like lesions.
The inflammation heals from the middle outwards and leaves a thinned scar.
Pemphigus erythematosus presents as a mixed image between a surficial pemphigus (see showcase 35) and a CDLE.
Apart from some scarring, the prognosis is quite good, because the disease only affects circumscribed areas.
Catalogue p. 45
This special form of LE stands between the CDLE, which is limited to the surface of the skin, and the systemic Lupus erythematosus (SLE).
Sunlight worsens the scaly, sometimes nodular, and sometimes annular reddening.
Catalogue p. 46
The chronic inflammation of the connective tissue can infest almost every organ. Characteristic autoantibodies are detectable in the blood.
Butterfly-like rash on the face in SLE.
Catalogue p. 46
Dermatomyositis is a chronic inflammatory autoimmune disease with progressive muscle weakness and skin changes. It may be a sign for a malignant tumour of the inner organs (Paraneoplasia, see also showcase 41).
Dermatomyositis with scaly changes on the hands, violet-reddish inflammations and a thinning of the skin.
Additional moulages on autoimmune diseases in showcase
There are two autoimmune diseases belonging to Scleroderma, because they lead to scarring and hardening of the skin: the circumscribed Scleroderma (Morphaea), with a good prognosis, and the systemic Scleroderma with a more severe prognosis.
Catalogue p. 47
Morphaea starts with a slight redness of the skin, slowly forming a hard and scarry plate in the centre. Usually the inflammation is limited to a few spots.
An overlap of Morphaea with Lichen sclerosus et atrophicus, another rare autoimmune disease of the connective tissue.
Catalogue p. 48
The prognosis of this systemic illness of unclear origin is difficult to assess. Apart from favourable progressions, there still exist forms that are hard to treat and lead to disablement. The involvement of the heart and kidneys is life-threatening.
The skin is tight, increasingly limiting mobility. Small ulcers and mutilations may develop on the fingertips.
Sclerotic scarring appears on the skin, accompanied by widened capillaries. As shown in this moulage, calcium deposits may develop underneath the skin, indicated by pressing a finger on a sclerotic plaque on the left temple area.
Catalogue p. 48
Dermatitis herpetiformis causes a burning itch. Typical antibodies against an enzyme which breaks down the cereal protein gluten are found in the blood. The same antibodies also cause intestinal inflammation (coeliac disease, sprue). By consistently following a gluten free diet, antibodies decrease and symptoms improve.
A stable blister on a typical location.
Patients with Dermatitis herpetiformis are also sensitive to iodine. In the past, testing with iodine on the skin used to be a diagnostic tool.
Catalogue p. 49
Antibodies in Pemphigus diseases react with structure proteins of the epidermis and lead to superficial blisters and erosions.
Pemphigus vulgaris
Pemphigus vulgaris is the most common form of Pemphigus. Infections as well as loss of fluid and salts are a threat to the patient. If the mucous membrane of the mouth is affected, drinking and eating becomes agonising.
Depending on localisation and pattern, different forms of Pemphigus may be distinguished. Superficial blisters in the armpit burst immediately and leave persistent wounds.
Catalogue p. 51
The antibodies of pemphigoid diseases react with proteins of the basal membrane. Bulging blisters develop at the border of the epidermis and the dermis. The epidermis forms the stable roof of the blisters.
Additional moulages on autoimmune diseases in showcase 54, left side.
Genodermatosis describes rare, genetically inherited skin diseases. Defects in the genetic code can lead to various changes in skin, hair, and nails as well as to keratinization and pigment shifting.
Catalogue p. 58
Patients with Xeroderma pigmentosum suffer from a deficiency in their DNA* repair mechanism, leading to the defective repair of UV--exposed skin. The increased photosensitivity leads to severe damage of the skin and skin cancer from early childhood (moulages 528 and 763). Only the complete avoidance of sunlight can prevent the formation of skin cancer.
*DNA: genetic code in the nucleus of every cell
Ichthyosis (fish scale disease)
There exist different types of inheritable keratinization -diseases. The mild form of Ichthyosis vulgaris with dry and sensitive skin is very common. Due to its brownish, scale-like desquamations, it is also named fish scale disease.
In the past, patients with this rare and stigmatising disease were shown on funfairs or in panoptikums as “snake men” or “fish people”.
This very rare form with most serious keratinization defects leads to the child’s death during pregnancy or shortly after birth.
Strongly pronounced Ichthyosis vulgaris. Nowadays, Vitamin A acid derivates (retinoids) may improve the keratinization disorder.
Neurofibromatosis Type 1 (von Recklinghausen’s Disease)
Moulages in showcase 50, left side.
Catalogue p.59
Tuberculosis bacteria or fungi may induce the accumulation of typical inflammation cells forming granulomas. Granulomas also develop due to inflammation of unknown cause. In skin, these include i. a. Granuloma anulare and Sarcoidosis.
Catalogue p. 60
Sarcoidosis is a granulomatous inflammation which can affect every organ. About 40% of patients suffer from inflammations of the skin.
The inflammation leads to large, bluish-reddish tumours - in the face especially on the nose, the cheeks and earlobes - or to plaques on the forehead.
Small brownish-reddish nodules are found on the skin, sometimes forming a ring.
In rare cases, the rash spreads over the entire body.
Catalogue p. 59
The cause for this harmless skin disease with no symptoms other than some slightly reddish papules is unclear. The skin eruption may persist over years and disappear without therapy.
Most commonly, the annular shaped focuses occur on the joints of hand, foot and elbow of children and adolescents.
Pigment changes
Catalogue p. 53
Small, sharply defined, light-brown spots are named Lentigines because of their lenticular size and colour. They consist of a collection of normal pigment-forming cells and are always harmless.
On light skin types Lentigines multiply due to chronic UV-light stress and appear, together with sunlight-independent seborrheic keratosis, as age spots (see also showcase 44).
Additional moulages on granulomatous diseases and pigment disorders in showcase 50, right side.
Catalogue p. 53
The destruction of pigment producing cells of the skin by the immune system leads to sharply bordered white spots. The development is unpredictable. Sometimes almost the entire skin turns white, sometimes the process stops early on and the spots become smaller.
The disease is harmless but brings with it a huge cosmetic impairment and psychological burden. Mechanical exposure or inflammatory irritation can provoke new spots (compare: Köbner-Phenomenon in showcase 40).
Most often affected are the face, neck, axillary fold, back of the hand, nipples and the genital area.
Melasma
Harmless, dark, and therapy resistant spots in the face, especially on women, often caused through pregnancy.
Catalogue p. 61
Pityriasis rosea (Morbus Gibert)
Oval spot on the torso that appears most often in young adults. It scales off easily and is often confounded with skin fungus.
Starting with the mother spot (tâche mère), further light red oval spots develop on the torso.
Changes disappear without therapy after a few weeks. Sometimes a too intense therapy even worsens the disease and the spots start to itch. As cause an infection is supposed, however, the pathogen is still unknown.
Secondary stage syphilis looks exactly the same and must not be missed in diagnosis (see showcase 19).
This group includes rare and very diverse diseases. Historically this classification was created to distinguish these diseases from psoriasis.
There exists a chronically proceeding, small-spotted parapsoriasis with harmless, eczema-like spots, which are not causing any complaints. The cause is unknown and the progress often tenacious. The similar, large-scaled form can merge into a lymphoma (see showcase 46).
Underlying the Pityriasis lichenoides et varioliformis acuta is a superficial inflammation of the blood vessels of unknown cause, leading to papules, necrosis, blisters and crusts. The rarely occurring feverish form can be dangerous.
Additional moulages on autoimmune diseases in showcase 51, left side.
Catalogue p. 38
Prurigo describes a host of diseases which start with itchy pustules that will get scratched and often remain on the skin for a lengthy period. There exist acute, subacute and chronic forms. Most often, the causes remain unclear, but often a tendency for dry skin, itching and eczema is associated.
Itchy pustules and blisters will be scratched until they bleed, after which the itch subsides. Due to the scratching, thickened and scarred pustules develop.
Scratched pustules with bloody crusts, scratched out papules and bright scars, surrounded by dark colouring as a sign for a past inflammation.
Catalogue p. 61
Psoriasis is a predisposition to reddish, scaly inflammations of the skin with the possibility of affected joints. Newest research suggests connections between psoriasis, cardiovascular diseases and diabetes mellitus.
On the skin, there is a differentiation between Psoriasis vulgaris with different subdivisions and Psoriasis pustulosa with its subdivisions. Serious progression can lead to reddening and desquamation of the entire skin surface.
The most common form is Psoriasis vulgaris with sharply bordered erythemato-squamous plaques on the hairy head, elbow, knee, in the umbilical area and in the cleft between the buttocks.
Due to the chronic progression, the focus spreads annularly (annular or gyrated Psoriasis).
During childhood or due to acute triggering through infection or medication, drop- or coin-shaped focuses appear on the entire body (Psoriasis guttata, nummular Psoriasis).
This form of Psoriasis on palms and soles with reddening, desquamation and fissures is hard to distinguish from a chronic Eczema. Pustules form with sterile pus on hands and feet, as shown in this moulage, and often proceed very persistently.
Psoriasis plaque on the back of the hand as well as nail changes which look like nail fungus (see catalogue p.56).
Acrodermatitis continua suppurativa shows a relation to pustular psoriasis. The inflammation progresses chronically, leading to serious and consistent nail changes, and the loss of the nail.
Additional moulages on autoimmune diseases in showcase 51, left side.
