Dermatologic Physical Exam

Primary Lesions

The earliest lesions of PV are erythematous, scaling papules 1 to 2 mm across, which enlarge in a centrifugal fashion (see Photo 22). The papules may enlarge singly or coalesce with other papules to produce solid plaques that cover large areas (see Photo 23). Color can vary from pink, to bright or dusky red. Color fades visibly as lesions go into remission. Thickness also varies, and increased thickness correlates directly with disease activity.

Secondary Lesions

1. Scale is loose and silvery, often referred to as "micaceous" or mica-like (see Photo 24).

2. Fissures are seen on occasion with intertriginous psoriasis.

3. Hyperpigmentation often occurs as lesions resolve and takes the shape of the resolving plaque (see Photo 25).

4. Hypopigmentation may also occur with resolution. Usually it has the shape of the resolving lesion.

Degree of scale varies dramatically from barely visible to scale so thick that the underlying plaque is totally obscured. Thickness of scale correlates directly with disease activity and is also altered by a patient's personal hygiene. When the scale is lifted from a plaque, a moist exudative surface is left, which is the epidermal layer immediately above the dermal papillae. Often this action will cause areas of pinpoint bleeding on the plaque surface from trauma to the exposed dermal capillaries. This is referred to as the Auspitz sign, and strongly supports the diagnosis (see Photo 26).


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