Identification of Primary and Secondary Dermal Lesions Protection Status
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By Laurie Swezey RN, BSN, CWOCN, CWS, FACCWS

There are numerous types of dermal lesions that may affect the skin. Dermal lesions may be classified as either primary or secondary lesions:

Primary Lesions

Primary lesions may be present from birth (i.e. birth marks) or may develop later in life (i.e. moles). Acquired skin lesions may result from an infectious disease, an environmental agent or an allergic reaction. Primary lesions appear different from their surrounding skin and are easily identified. The following definitions fall under the category of primary lesion:

  • Vesicle: a fluid-filled blister which is less than 5mm in diameter, elevated above the level of the skin with well demarcated borders
  • Bulla: a large vesicle (greater than 5 mm in diameter)
  • Pustule: a pustule is similar in appearance to a vesicle or bulla, but contains purulent material
  • Macule: colored red, brown, tan or white, macules have defined borders and are flat
  • Nodule: nodules are firm to touch, elevated and easily palpable and may involve all layers of the skin
  • Wheal: irregularly shaped area of edematous skin; may come and go and may appear white, pink or red in color. Wheals are often elevated above the skin and have irregular sizes/shapes
  • Plaque: a plaque is elevated, irregular, firm, flat and rough in texture; they may come together in one area to form plaques.
  • Telangiectasias: small dilated blood vessels that occur near the surface of the skin; may appear in a spoke-and-wheel formation, or may appear spider-like, with several “legs” spreading out from a center.

Secondary Lesions

Secondary lesions occur when skin affected by a primary lesion undergoes change related to manipulation, treatment or disease progression. The following are examples of secondary lesions:

  • Crust: contains dried blood, serum or exudate, is elevated slightly above the level of the skin and may cover variable sized areas of skin (may be very large or very small area)
  • Scale: keratinized cells that grow one on top of another, may be flakey and easily removed; irregular in size, dry or oily, thin or thick; may be white or cream-colored
  • Excoriation: scratches that may break the skin, often linear and caused by fingernails
  • Lichinification: occurs when the epidermis becomes thickened and rough due to chronic scratching or rubbing of the skin
  • Atrophy: occurs when the skin becomes thin and fragile; occurs frequently in elderly people and people using topical steroids for long periods of time
  • Scarring: occurs when normal skin is replaced by discolored and fibrous scar tissue
  • Ulcer: ulcers may involve the uppermost layer of skin (the epidermis) or may extend down into the dermis; may occur acutely or chronically

Dermal Lesion Treatment

Treatment of skin lesions includes identifying the type of lesion (primary or secondary), the underlying cause of the lesion and the patient’s health status. Treatment may include corticosteroids, antibiotics, antifungal aids and other medications given systemically or topically.

When cancer is suspected, the lesion will be biopsied and a small section of the lesion will be examined under a microscope. Patients who develop a new skin condition should see their physician for advice, as should patients who experience a reoccurrence or worsening of a previously diagnosed skin lesion or condition.

Wound care patients should be encouraged not to pick at, rub or scratch lesions. Nails should be kept short and skin should be kept as clean and moisturized as possible. Skin should also be examined monthly for the appearance of new lesions or changing lesions that may signify an early skin cancer.

Hess, C (2005). Clinical Guide: Wound Care. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins
Miller, J. & Marks, J. (2006). Lookingbill and Marks' Principles of Dermatology. Saunders

About The Author
Laurie Swezey RN, BSN, CWOCN, CWS, FACCWS is a Certified Wound Therapist and enterostomal therapist, founder and president of, and advocate of incorporating digital and computer technology into the field of wound care.

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.

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