Efflorescences A1.1

Author: Prof. Dr. med. Peter Altmeyer

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Last updated on: 29.10.2020

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The theory of efflorescence is the historically influenced catalogue of terms, the alphabet that must be learned to describe and communicate a skin disease. The basic terms of the efflorescence theory (efflorescence or skin bloom) were developed by our dermatological ancestors in the 17th and 18th century from the already existing system of botany. Prominent representatives of these generations are Thomas Sydenham (1624-1698) from England, his London countryman Robert Willan (1757-1812) and his student Thomas Bateman (1778-1821) as well as later the members of the Paris School around Baron Jean Louis Alibert (1766-1831) and those of the Vienna School around Ferdinand v. Hebra (1816-1880) and his son-in-law Moritz Kaposi (1837-1902).

History and today

The recording of efflorescence is then as now purely descriptive. Efflorescence in itself says nothing about the nature of the lesion. The description of efflorescence is based on apparently simple terms such as primary and secondary chlorescence. Primary efflorescences are defined as:

Furthermore, secondary lesions have been defined and described which follow a primary efflorescence such as: scaling, weeping, swelling, crustal formation, atrophy, scars, erosions, ulcers, rhagades, fissures, a poikilodermatic (colourful multiform) skin condition and necroses.

The distinction between primary and secondary chlorescences was undoubtedly introduced for didactic reasons by Ferdinand v. Hebra in the century before last. This distinction makes little sense from a differential diagnostic point of view. Jadassohn saw it this way already in 1930 and Siemens in 1952. Jackson writes about this: "Please note, that at no time do I use the terms primary or secondary with regard to descriptive morphological terms. What is seen is there".

However, what is seen must also be recognized, processed and evaluated (diagnosed). This requires constant, daily morphological training. It is an absolute misconception that one only has to have a dermatological atlas at hand, find a suitable image for the clinical picture at hand and the diagnosis is ready. Such a striking way of thinking contradicts any clinical experience. Knowledge, morphological comprehension, experience and imagination are the prerequisites for a good dermatological diagnosis. It is necessary to recognize colors and surface structures of efflorescences and to evaluate their morphological variability, consistency and interrelation. And finally, the leading symptoms have to be worked out from the clinical picture and characterized. Only then does the actual, often laborious path to diagnosis begin.

To find a diagnosis, a very easy to grasp description of the findings is sufficient which is based on the following terms:

  1. Spots
  2. Increases
  3. Deepening
  4. Hardenings
  5. Bearings

1. spots (colour changes of any kind); large spots are also called patches

2. elevations of the skin divided according to:

  • solid elevations and
  • non-solid increases (protype=bubble)

Solid elevations of the skin

  • Papule (circumscribed skin elevation < 1.ocm)
  • Plaque (a two-dimensional elevation, >1.0 cm)
  • wheals (volatile increase due to cutaneous oedema)
  • Nodules (circumscribed tissue consolidation lying in the skin or subcutis or projecting above the skin level > 1.0 cm)
  • Swelling (diffuse large-scale crescent-shaped elevation of the skin due to deep-seated fluid proliferation).

Non-solid elevations filled with liquid

  • Bubbles/bubble (elevation filled with liquid)
  • Pus blister/bubble (elevation filled with pus)

3. depressions in the skin surface:

  • Scar
  • Atrophy
  • Erosion
  • Ulcer

4. indurations (hardenings, only palpable, superficial or deep, flat or nodular tissue hardening)

5. deposits (scaling, crusts, weeping).

The efflorescence group "elevations" needs further subdivision into solid and non-solid elevations. Solid elevations include: papules, plaque, wheals and nodules. Non-solid raised areas include all blistery or pustular efflorescences. Blisters and pustules are also easy to diagnose efflorescences for non-dermatologists. So are the solid sublime ones. A papule is "more than a spot", it is always palpable.

The difference between papules and nodes is determined by size scale. A lump is more voluminous and larger than a papule (> 1.0 cm). It is just as easy to distinguish between papules and plaque. A plaque is not thicker than a papule, but only larger in area. Here, too, > 1.0 cm is the standard size. A plaque develops from papules that are moved together and fused to form a (plate-like) plateau, or from a centrifugally growing papule (example: Granuloma anulare) that exceeds its defined size of 1.0 cm.

The distinction between papule and urtica and between plaque and urtica appears complicated at first glance. If it does not succeed right away, the dynamics of efflorescence must be investigated or measured. A wheal, whether large or small, exists as a single florescence only for about 8 to a maximum of 12 hours. By marking the efflorescence, the differentiation is very precise. The marked wheal, unlike its size, is in any case gone after 12 hours.

The subcutaneous swelling, a dynamically developing, cushion-like soft skin bulge, is a phenomenon that is clinically easy to detect, but etiologically often difficult to evaluate.

A deepening of the surface can have very different causes. It can be caused by a chronically creeping tissue atrophy (skin, subcutis or deeper lying structures) without a visible defect of the surface, by an acute or chronic trauma (traumatic tissue defect of varying extent), by a neoplastic or nutritive induced tissue loss. The morphological finding "skin ulcer", describes an open tissue defect of different etiology.

Colours and surface structures of the efflorescences

The red, non-anaemic spot is often equated with the term purpura as efflorescence. Although the term purpura is familiar to every physician, this term is subject to major attempts at interpretation. On the one hand, the term purpura refers to efflorescence. On the other hand, purpura comprises a pathogenetic description of a process in the skin, a bleeding into the skin. Finally, the term purpura also describes a diagnosis, e.g. the "Purpura Schönlein Henoch". A look into a "dermatological encyclopaedia" shows the main keyword "purpura" 57 times (!). We meet this registration mania, accumulated over 1.5 centuries, with the greatest respect, even though it does not promote the understanding of these terms by non-dermatologists. The spectrum of purpura terms ranges from Purpura cryoglobulinämica to Purpura pigmentosa progressiva and Purpura Schönlein. This diagnostic dilemma is fatal for the teaching of "pattern recognition" of pattern recognition. So let us solve this Gordian knot with a courageous cut by throwing off historical ballast, accepting the given (the internationally naturalized naming) and cultivating a puristic naming system.

At this point, we will choose a simple descriptive-clinical approach and thus avoid history.

The red spot. In principle, a red spot can only be created by a focal increase in the density of erythrocytes in the dermis. If this is caused by a simple hyperemia, the red spot can be anaemized: the red colour can be made to disappear completely by applying suitable pressure (glass spatula or even the thumb). The term for an anaemic red spot is "erythema".

A red spot that cannot be anaemized can only be caused by erythrocyte extravasations (these cannot be removed by pressure, they remain in place even under strong glass spatula pressure. The red colour does not give way). There are only two possible interpretations for a non-anemiable red spot. Either it is a non-inflammatory (e.g. traumatic) bleeding into the skin or, otherwise, it is an inflammatory reaction at the dermal blood vessels, which leads to an increased permeability of blood components (especially erythrocytes). Therefore, a focal bleeding into the skin can also be detected here.

The differentiation between erythema and a haemorrhagic red spot is of great diagnostic and thus also therapeutic importance. In the case of a hemorrhagic spot, i.e. bleeding into the skin, specific examination steps will be necessary to clarify the phenomenon. Thus it makes sense to distinguish between non-inflammatory bleeding into the skin (e.g. traumatic) and inflammatory skin bleeding (e.g. haemorrhagic vasculitis, haemorrhagic urticaria or haemorrhagic measles).

Notice! The colour "red" is of great importance for morphological diagnostics in white skin. In brown skin it loses its importance due to the colour overlay.

Of course, this statement also applies to other skin diseases which are distinguished by their particular red colouring and thus also to the morphological problem of the red spot which is even more difficult to solve in black skin. We therefore refer exclusively to the "Caucasian" white skin in our colour gradings. The dermatological diagnosis of colored persons requires a different algorithm adapted to brown or black skin.

The colours brown and black play an important role in the differential diagnosis of pigment and vascular tumours, among other things. For example, a particularly subtle examination may be required to distinguish a deep black seborrhoeic keratosis (benign) from a nodular malignant melanoma. In case of a clinically questionable determination and remaining suspicion regarding the dignity of the tumour, histological examination will be indispensable.

In this eminently important differential diagnosis, the incident light microscopic examination helps us today. Based on special surface features (e.g. pseudohorn cysts), the diagnosis "seborrheic keratosis" and thus its benignity is further confirmed.

Further colours are:

  • skin colour
  • whitish
  • yellow (yellow-brown; yellow-red; yellow-green)
  • brown (light brown; deep brown; brown-black)
  • red (light red; rich trot; dark red; red-livid)
  • blue
  • black
  • other (green)

The differentiation of the different genuine colours of skin changes is important to be able to correctly classify the location of inflammations or pigments in different diseases.

The surface structures can be distinguished:

  • normal/smooth - like the surrounding skin
  • smooth atrophic (parchment-like)
  • bumpy
  • wrinkled
  • horny, calloused
  • hypertrichotic (increased hair growth)
  • hypotrichotic (reduced hairiness)
  • crusty
  • weeping
  • rough
  • scaly
  • dry
  • warty (papillomatous)
  • excommunicated
  • umbilical
  • Wickham's striped pattern.

This section has been translated automatically.

This section has been translated automatically.

The distinction between primary and secondary chlorescences was introduced by Ferdinand v. Hebra in the century before last. It makes no sense and can be abandoned neither for didactic reasons nor from the point of view of a differential diagnostic evaluation of a disease. This is how Jadassohn saw it in 1930 and Siemens in 1952. Jackson writes about this: "Please note, that at no time, do I use the terms primary or secondary with regard to descriptive morphological terms. What is seen is there". In this respect, the system can be reduced to 5 morphologically very easy to grasp descriptions of findings for the purpose of finding a diagnosis and also as a proposal for simplifying the theory of efflorescence:

This section has been translated automatically.

  1. Altmeyer P (2007) Dermatological differential diagnosis. The way to clinical diagnosis. Springer Medicine Publishing House, Heidelberg
  2. Nast A, Griffiths CE, Hay R, Sterry W, Bolognia JL. The 2016 International League of Dermatological Societies' revised glossary for the description of cutaneous lesions. Br J Dermatol. 174:1351-1358.
  3. Ochsendorf F et al (2017) Examination procedure and theory of efflorescence. Dermatologist 68: 229-242


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Last updated on: 29.10.2020