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linicians are sometimes first be able to recognize prima- mary and secondary lesions, ted for diagnostic testing (espe-
surprised when they re- ry and secondary lesions and carefully evaluate the animal to cially biopsies for histopathologic
fer an animal with a der- be able to associate them with a determine the predominant pat- assessment).
matologic problem to a specialist predominant morphologic pat- tern. This is done by asking a se-
who rapidly compiles a list of dif- tern. This column focuses on ries of questions in a specific or- Perform Diagnostic
ferential diagnoses and pinpoints the evidence that clinicians can der (see the algorithm). Always Testing
specific tests to be performed. see during a clinical examina- select the predominant pattern. A With a pattern diagnosis and
There is nothing magical about tion; this evidence is coupled dog with profound scaling and differential diagnostic list, the
the dermatologist’s action! Al- with the patient history to nar- three pustules does not have a possible diagnoses can be nar-
though dermatologists routinely row the diagnostic possibilities. vesiculopustular disorder; it has rowed. With experience, it is
see various cutaneous lesions, it Although seemingly easy,
is their ability to properly identify correctly describing a skin con-
■ Most dermatologic problems have a characteris-
these lesions that provides the dition can be quite difficult. To
tic clinical presentation.
critical information necessary to do pattern diagnosis effectively,
KEY POINTS
compile a list of diagnostic differ- descriptions must be precise ■ A differential diagnostic list can often be made
and accurate. Differentiating a
by assigning clinical cases into one of eight
entials and select appropriate
major categories of predominant lesion patterns.
testing. scale from crust or a papule
Key to making a diagnosis from a plaque, for example, is ■ Deciding which diagnostic tests to perform
and treating a previously unseen critical. Without a correct de- becomes more routine if the lesions have been
scription of the morphologic
grouped into one of the eight major categories.
dermatologic problem is keep-
ing an open mind to the possi- pattern, accurate diagnosis is
bility of a novel diagnosis and usually impossible. Table One an exfoliative dermatosis. A cat possible to prioritize the most
starting with the usual history provides an easy-to-use list of with a large, hairless mass on its likely diagnoses and perform
taking. After a very thorough lesions, their descriptions, and back has a papulonodular der- tests accordingly. At first, how-
history, the basic morphology the morphologic pattern associ- matosis, not alopecia. There are ever, information in Table Ten
of cutaneous lesions must be ated with each. In summary, eight major categories of pre- can be used to create a mini-
dominant patterns. mum data base, which will reveal
the most common condition as-
How To Make a Correct Formulate Differential sociated with a particular presen-
Dermatologic Diagnosis Diagnostic List tation. If the minimum data base
Once you have determined the does not suggest a diagnosis,
Step 1 Determine pattern. fit between your case and one of proceed to the “next step” col-
Step 2 Formulate differential diagnostic list. the eight major categories, you umn in Table Ten. By following
Step 3 Perform diagnostic testing. can create a comprehensive dif- this approach, a diagnosis can
ferential diagnostic list from the be made in most cases.
Initial Algorithm Key
Primary pigmentary
Description of lesions
Small Animal
changes ?
Predominant lesion patterns
no
Raised lesions ?
no
yes
Flat, depressed, or mildly
elevated lesions ?
Fluid-filled lesions ?
no
no yes
no
yes
Scaling prominent ?
yes
no
yes no
Pigmented Erosive-
Vesiculopustular Papulonodular Alopecic Exfoliative Indurated Maculopapular
lesions and ulcerative
dermatoses dermatoses dermatoses dermatoses dermatoses dermatoses
dermatoses dermatoses
The Compendium September 1996
The Compendium September 1996 Small Animal
TABLE ONE
Pattern Diagnosis
Lesion Description Pattern Association
Macule A circumscribed, flat discoloration of the skin up to Maculopapular
1 cm in diameter Pigmented
Patch Macules >1 cm Maculopapular
Pigmented
Papule A circumscribed, elevated, superficial, solid lesion Maculopapular
up to 1 cm in diameter
Plaque A circumscribed, elevated, superficial, solid lesion Papulonodular (plaque)
>1 cm; a papule that has enlarged in two dimensions
Wheal An edematous, transitory papule or plaque Papulonodular (plaque)
Indurated (turgid)
Nodule A solid lesion with depth; a papule that has enlarged Papulonodular (nodule)
in three dimensions
Vesicle A circumscribed elevation of the skin up to 1 cm in Vesiculopustular
diameter and containing serous fluid
Bulla A vesicle >1 cm in diameter Vesiculopustular
Pustule A circumscribed elevation of the skin containing Vesiculopustular
purulent fluid
Epidermal collarette A circular peeling rim of scale Vesiculopustular
Petechia A circumscribed deposit of blood or blood pigment Pigmented (red)
up to 1 cm in diameter
Purpura A circumscribed deposit of blood or blood pigment Pigmented (red)
>1 cm in diameter
Scale Shedding dead epidermal cells that may be dry or Exfoliative
greasy Maculopapular
Crust Variously colored collections of skin exudates Erosive-ulcerative
Excoriation Abrasion of the skin, usually superficial and Maculopapular
traumatic in origin
Fissure A linear break in the skin that is sharply defined Maculopapular
with abrupt walls Papulonodular
Exfoliative
Erosion An excavation in the skin limited to the epidermis Erosive-ulcerative
and not breaking the integrity of the
dermoepidermal junction
Ulcer An irregularly sized and shaped cavitation in the Erosive-ulcerative
skin extending into the dermis
Scar A formation of connective tissue replacing tissue Indurated
lost through injury or disease
Lichenification A diffuse area of thickening and scaling, with Maculopapular
resultant increase in the skin lines and markings Indurated
Exfoliative
Induration Palpable thickening of the skin Indurated
Sclerosis Hardening of the skin Indurated
Hyperpigmentation Darkening of the skin Pigmented (dark)
Maculopapular
Small Animal The Compendium September 1996
TABLE TWO
Differential Diagnosis for Pigmented Lesions
Category Canine Feline
Red Drug eruption Drug eruption
Petechiae Petechiae
Purpura Purpura
Vasculitis Vasculitis
Contact dermatoses Contact dermatoses
Lupus erythematosus Lupus erythematosus
Photodermatitis Photodermatitis
Erythema multiforme Erythema multiforme
Skin-fold pyoderma Eosinophilic plaque
Pyotraumatic dermatitis Linear granuloma
Histiocytoma
Demodicosis
Flushing syndrome
Lyme borreliosis
Hookworm dermatitis
TABLE THREE
Differential Diagnosis for Vesiculopustular Lesions
Category Canine Feline
TABLE FOUR
Differential Diagnosis for Papulonodular Lesions
Category Canine Feline
Nodular Parasitoses Abscess
Deep pyoderma Acne
Atypical pyoderma Atypical pyoderma
Dermatophytosis Dermatophytosis
Intermediate mycoses Intermediate mycoses
Deep mycoses Deep mycoses
Lupus profundus Parasitoses
Neoplastic Neoplastic
Dermoid cyst Dermoid cyst
Nodular panniculitis Nodular panniculitis
Juvenile cellulitis Lupus profundus
Mucinosis Xanthoma
Eosinophilic granuloma Eosinophilic granuloma
Sebaceous adenitis Leprosy
Sterile pyogranuloma Opportunistic mycobacteria
Opportunistic mycobacteria
Acral pruritic nodule
Calcinosis circumscripta
Nodular fasciitis
Protothecosis
Dracunculiasis
TABLE FIVE
Differential Diagnosis for Alopecia
Category Canine Feline
Focal/multifocal Demodicosis Demodicosis
Bacterial pyoderma Bacterial pyoderma
Dermatophytosis Dermatophytosis
Alopecia areata Alopecia areata
Cutaneous asthenia Cutaneous asthenia
Traction alopecia Traction alopecia
Morphea Injection site reaction
Injection site reaction Cicatricial alopecia
Cicatricial alopecia
TABLE SIX
Differential Diagnosis of Erosive-Ulcerative Lesions
Category Canine Feline
Parasitic Fleas Fleas
Demodicosis Demodicosis
Sarcoptic mange Notoedric mange
Leishmaniasis
TABLE SEVEN
Differential Diagnosis for Exfoliative Lesions
Category Canine Feline
Patchy Ectoparasitism Ectoparasitism
Dermatophytosis Dermatophytosis
Drug eruption Drug eruption
Pemphigus foliaceus Pemphigus foliaceus
Fatty acid deficiency Fatty acid deficiency
T-cell lymphoma Protein deficiency
Pagetoid reticulosis Vitamin A deficiency
Sjøgren’s syndrome Vitamin E deficiency
Hyperestrogenism Biotin deficiency
Vitamin A–responsive dermatosis Lynxacariasis
Sebaceous adenitis Adverse food reactions
Generic dog food disease Perforating dermatitis
Subcorneal pustular dermatosis
Chronic maculopapular dermatoses
Parapsoriasis
Adverse food reactions
Hypothyroidism
Lupoid dermatosis
Leishmaniasis
Small Animal The Compendium September 1996
TABLE EIGHT
Differential Diagnosis of Indurated Lesions
Category Canine Feline
Turgid Urticaria Urticaria
Angioedema Angioedema
Myxedema Growth hormone–secreting tumor
Juvenile cellulitis Mucopolysaccharidosis
Mucinosis Relapsing polychondritis
Nephrotic syndrome Plasma cell pododermatitis
Urticaria pigmentosa
Hookworm dermatitis
TABLE NINE
Differential Diagnosis of Maculopapular Lesions
Category Canine Feline
Macular Allergic inhalant dermatitis Allergic inhalant dermatitis
Food allergy Food allergy
Allergic contact dermatitis Allergic contact dermatitis
Irritant contact dermatitis Irritant contact dermatitis
Drug eruption Drug eruption
Bacterial pyoderma Erythema multiforme
Lupus erythematosus Endoparasite infection
Erythema multiforme Ectoparasite infestation
Alopecia areata Lupus erythematosus
Endoparasite infection Alopecia areata
Ectoparasite infestation
Acanthosis nigricans
TABLE TEN
Step-by-Step Approach to Diagnosis
Classification Minimum Data Base Next Step
Pigmented Histopathology As per biopsies
Indurated
Turgid Complete blood count Histopathology
Biochemistries
Urinalysis
Fecal tests
Figure 1—A dog with regional (nasal) alopecia and associated Figure 2—A cat with an erosive-ulcerative dermatosis. The
exfoliative dermatosis. The most likely clinical diagnoses were most likely clinical diagnoses were hypersensitivity disorders,
lupus erythematosus (systemic or discoid), pemphigus (foli- parasites, microbial infections, and immune-mediated der-
aceus or erythematosus), dermatomyositis, zinc-responsive matoses. Minimum data base consisted of skin scrapings and
dermatosis, and follicular dysplasia. Minimum data base con- impression smears. The skin scrapings were negative, but cy-
sisted of skin scrapings, culture for dermatophytes, complete tologic preparations revealed a mixed inflammatory cell popu-
blood count, routine biochemistry, and a trichogram. Only lation of neutrophils, eosinophils, and histiocytes; few mi-
the trichogram showed abnormalities, with telogen hairs pre- crobes were present. Hypersensitivity conditions were
dominating. Biopsies were then taken and histopathologic considered and a food trial confirmed a hypersensitivity to
analysis confirmed the diagnosis as dermatomyositis. beef.
The Compendium September 1996 Small Animal
Figure 3—A cat with an exfoliative dermatosis that is most prominent over the
top of the head. Minimum data base consisted of skin scrapings and cytologic
preparations (impression smears and acetate-tape impressions). The skin scraping
was positive for Notoedres cati.
Figure 4—A dog with regional alopecia and associated hyperpigmentation. Mini-
mum data base included skin scrapings, culture for dermatophytes, a trichogram,
complete blood count, biochemistries, and urinalysis. The trichogram revealed
that telogen hairs predominated. The only other abnormality was an increased
serum alkaline phosphatase level. Endocrine profiles confirmed a diagnosis of pi-
tuitary-dependent hyperadrenocorticism.
Figure 5—A dog with dermal nodules and plaques (a papulonodular dermatosis).
Minimum data base consisted of skin scrapings, cytologic preparations (fine-nee-
dle aspiration), and biopsies for histopathologic analysis. The cytologic prepara-
tions revealed a mononuclear population of cells, which were presumed to be
small lymphocytes. The histopathologic assessment confirmed the diagnosis as
cutaneous lymphoma.
Figure 7—A cat with an indurated (solid) and erosive-ulcerative dermatosis. Min-
imum data base included cytologic preparations (fine-needle aspiration and im-
pression smears) and biopsies for histopathologic analysis. The cytologic prepara-
tions revealed a pyogranulomatous infiltrate with histiocytes and giant cells. The
histopathologic assessment confirmed the diagnosis as nocardiosis. The cat had
concomitant FIV infection.
Acknowledgment
All photographs in this article are from Nesbitt GH, Ackerman LJ (eds): Dermatolo-
gy for the Small Animal Practitioner. Trenton, NJ, Veterinary Learning Systems, 1991,
Plates I, III, VI, VIII, IX, and X.