Abstract
These lesions are usually isolated and rarely multiple. Although precisely identifying the primary lesion is essential in establishing a differential diagnosis, it is important to note that there is significant overlapping between a papule, a plaque, and a nodule. Indeed, a single disorder can manifest simultaneously or successively as each of these lesions, either through their growth or confluence, or by nature. Since it is vital to diagnose melanoma and other pigmented cancers, a biopsy is indicated in case of the slightest doubt. This situation also requires that clinical examination sometimes be completed by a careful inspection using a magnifier lens or a dermatoscope. The latter may provide additional elements that can help avoid biopsy in some instances. However, histopathological examination remains the “gold standard” for establishing the precise diagnosis of any skin tumor. Certain lesions may have a purple coloration and thus reflect a dermal inflammation (e.g., lichen planus) or an angiomatous proliferation (e.g., Kaposi’s disease). Certain violaceous palpable lesions are angiokeratomas. When they are numerous and distributed over the “underwear” area, they can reflect an overload disease such as Fabry disease, which, if diagnosed early, can be treated by enzyme replacement therapy. Serious renal, cardiac, and/or cerebral complications can thus be avoided.
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These lesions are usually isolated and rarely multiple. Although precisely identifying the primary lesion is essential in establishing a differential diagnosis, it is important to note that there is significant overlapping between a papule, a plaque, and a nodule. Indeed, a single disorder can manifest simultaneously or successively as each of these lesions, either through their growth or confluence, or by nature. Since it is vital to diagnose melanoma and other pigmented cancers, a biopsy is indicated in case of the slightest doubt. This situation also requires that clinical examination sometimes be completed by a careful inspection using a magnifier lens or a dermatoscope. The latter may provide additional elements that can help avoid biopsy in some instances. However, histopathological examination remains the “gold standard” for establishing the precise diagnosis of any skin tumor. Certain lesions may have a purple coloration and thus reflect a dermal inflammation (e.g., lichen planus) or an angiomatous proliferation (e.g., Kaposi’s disease). Certain violaceous palpable lesions are angiokeratomas. When they are numerous and distributed over the “underwear” area, they can reflect an overload disease such as Fabry disease, which, if diagnosed early, can be treated by enzyme replacement therapy. Serious renal, cardiac, and/or cerebral complications can thus be avoided.
Main Causes of Brown, Black, Blue, or Gray Palpable Lesions
Acanthosis nigricans |
Acroangiodermatitis (pseudo-Kaposi’s sarcoma, arteriovenous fistula) |
Acrochordon or skin tag |
Angiokeratoma (usually violaceous) |
Angiolymphoid hyperplasia with eosinophilia and Kimura disease |
Angiosarcoma |
Black piedra |
Blue nevus |
Botryomycoma |
Bowenoid papulosis |
Cutaneous B-cell lymphoma |
Dermatofibrosarcoma |
Dermatosis papulosis nigra (Castellani’s disease) |
Glomus tumor (and glomangiomatosis) |
Hemangioma (cavernous and verrucous) |
Hidrocystoma |
Kaposi’s disease |
Leukemias (particularly acute myeloid leukemia 4 and 5, NK-lymphoma, and dendritic plasmacytoid CD56-positive lymphomas) |
Melanocytic tumors (melanoma, nevus, etc.) |
Metastases (particularly of melanoma) |
Open comedo and dilated pore of Winer |
Pigmented viral wart |
Purple papules in lichen planus, granuloma annulare, and collagen vascular diseases |
Seborrheic keratosis |
Skin cancers and precancerous lesions (pigmented basal cell carcinoma, pigmented Bowen’s disease, pigmented actinic keratosis, pigmented eccrine porocarcinoma, etc.) |
Urticaria pigmentosa |
Isolated lesions: melanoma and other pigmented cancers.
Multiple lesions (rare): metastases, namely, of melanoma, and leukemia cutis, as well as urticaria pigmentosa in cutaneous and systemic mastocytoses (usually macular), can have a brown coloration.
FormalPara CommonNevus, fibroma, and acrochordon.
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Lipsker, D. (2013). Brown, Black, Blue, or Gray Palpable Lesions. In: Clinical Examination and Differential Diagnosis of Skin Lesions. Springer, Paris. https://doi.org/10.1007/978-2-8178-0411-8_32
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DOI: https://doi.org/10.1007/978-2-8178-0411-8_32
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