How to make diagnosis of cutaneous Problem
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Transcript How to make diagnosis of cutaneous Problem
Prof. DOULAT RAI BAJAJ
FCPS, MCPS
Professor & Chairman
Dept. of Dermatology
LUMHS
How to Diagnose Skin
Disease
History
Examination
Investigations
History
Presenting Complaints
History of Presenting Complaints
Past History
Travel History**
Drug History**
Family history
Personal History
Socioeconomic history etc
HISTORY of Presenting Illness
Duration: When did it start?
Onset: sudden or gradual: varicella, P.Rosea
Does it itch, burn or hurt?
Where on the body it did it start?
Progress: How it spread on body; pattern of
spread
What changes have occurred?(evolution of lesions)
Aggravating/Relieving factors
Previous treatments; its effect on lesions
How to Diagnose a skin Disease
Evolution of lesions
How the lesion started?
What were initial signs?
For Example:
1. Viral lesions start as erythematous papules &
evolve into vesicles.
2. Porphyria cutanea tarda presents as vesicles on
hands progressing to scars.
3. Cutaneous T cell lymphoma starts as itchy
eczematous plaques papules and nodules
How to Diagnose a skin Disease
Symptoms
Pruritus is an important symptom of:
Atopic dermatitis
Allergic contact dermatitis
Biliary cirrhosis
Cutaneous fungal infections
Cutaneous lymphomas
Ch.Liver/Renal disease
Scabies
How to Diagnose a skin Disease
Pruritus is typically NOT present in:
Secondary syphilis
Leprosy
How to Diagnose a skin Disease
PAIN :
Skin diseases in which pain is an Important symptom:
1. Acute viral infections
2. Leiomyoma
3. Acute vasculitic lesions
4. Neurofibromas
5. Glomus tumour
Travel History
Travel
to endemic areas:
– Leishmaniasis
– Guinea worm
– Trypanosomiasis
Drug History
Sulphonamides: Many types
NSAIDs: SJS syndrome, psoriasis, TEN, urticaria
B-blockers: psoriasis, LE
ACEIs: Psoriasis, urticaria, angioedema
Diuretics: xerosis, photosensitivity
Minocycline: SLE, pigmentation
Chloroquin: bleaching of hair
Laxatives: FDE
ATT: LP
Personal History/Job/hobbies
ACD: Cement, fertilizers, domestic chemicals,
water, farmers etc
Dentists: herpetic whitlow
Fish Tank granuloma: pond workers, fish fanciers
Sporotricosis and other deep fungal infections:
horticultural workers, gardeners, forest workers
Photodevelopers: Lichenoid eruption
Acne: oil workers, industry workers
Radiologists, radiation workers: Skin carcinomas
Personal History contd……
Contact with animals pets:
–Ringworms
–Orf
–Erysipelas
–Histoplasmosis
Family History
Genodermatoses: neurofibromatosis,
TSC, XP
Scabies, chickenpox, pediculosis
EXAMINATION
Note the following Features:
Site
Distribution:
Generalized: psoriasis, LP, varicella, urticaria, drug
eruptions, AD
Localized:
Sebhorroic dermatitis: on sebhorroic areas
Scabies: genitals, finger webs, wrists, elbows, axillae
FDE: lips, genitals
DLE: Face, sun-exposed areas
PLE: Sun-exposed areas
Examination contd….
Morphology of lesions
Type of lesion: Papules, macules, patches,
plaques, bulla, ulcers, erosions etc
Size of lesion: Macule (freckles) vs patch (vitiligo)
Papule (warts) vs plaque (psoriasis)
Vesicle (viral) vs bullae (pemphigus)
Nodule (leprosy) vs tumous (BCC)
Shape/configuration:
annular, discoid, arcuate,
polycyclic etc.
Surface: smooth (keloid), rough (psoriasis)
keratotic (warts)
Examination contd
Colour:
red (psoriasis, eczemas), skin coloured
(acne, warts, neurofibromas), violacous (LP), black
(tatoos, melanoma), slate gray (syphilis), pale
(PV), milky white (vitiligo), pink (P rosea)
Consistency: solid (warts, LP), cystic (MC, Sebaceous
cyst), vesicular (viral), bullous (pemphigus, pemphigoid)
Margins: well demarcated (psoriasis, erysipelas),
poor demarcated (cellulitis, leprosy)
Examination contd….
Pattern:
Discrete: molluscum, warts, chickenpox
Grouped: herpes simplex, plane warts, lichen nitidus,
Segmental: vitiligo, nevi
Dematomal: herpes zoster, vitiligo
Bizarre: incontitia pigmenti, dermatitis artefacta
Scattered: extensive: many types of eczemas
Symmetry: Symmetrical (psorisis, AD, Discoid eczema),
Asymmetical( tinea, TB)
Linear:
How to Diagnose a skin Disease
Guttate psoriasis:
discrete lesions on
chest
How to Diagnose a skin Disease
Bizarre pattern: Verrucous epidermal nevus
linear
Occur due to involvement of
dermatome, blood vessels or
lymphatics.
May be developmental origin.
May follow Blashko’s lines.
Koebner phenomenon.
Examination contd…
Shape/Configuration
– Annular (centre clear): Tinea, LP, psoriasis
– Discoid (centre filled) : discoid eczema,
psoriasis, UV
– Arcuate (incomplete circles): urticaria
– Serpiginous (snake): cutaneous larva migrans
– Reticulate: livido reticularis, cutis mormorata
– Polycyclic: psoriasis
– Target: EM
How to Diagnose a skin Disease
Arcuate
:An arc like or moon shaped
arrangement.
e.g. Stevens Jhonson syndrome
How to Diagnose a skin Disease
Arcuate lesions:
Stevens Johnson
Syndrome
How to Diagnose a skin Disease
Satellite
Candidiasis
leishmaniasis
Lesions
How to Diagnose a skin Disease
Satellite lesions: candidiasis
How to Diagnose a skin Disease
Location/Site of lesion
Psoriasis: Extensor areas, scalp & nails
Vasculitis: Feet, lower limbs, buttocks
E. Nodosum, P.gangrenosum: legs, thighs
DLE: face, nose, pinnae, neck
SLE: malar area of face, bridge of nose
Herpes simplex: near muco-cutanous junction
Herpes zoster: in zosteriform distribution
How to Diagnose a skin Disease
Secondary syphilis: trunk, palms & soles
Pityriasis versicolour: Trunk, back, arms
Atopic dermatitis: cheeks, wrists, flexures
Porphyria: face, dorsa of hands & feet
Lichen Planus: wrists, lumbar regions, oral
mucosa
Pemphigus Vulgaris: Head and upper trunk
Adenoma sebaceum of TSC: around nose
Stevens Johnson Synd: Acral parts and
mucosal surfaces
How to Diagnose a skin Disease
Trans
Carry
location of lesion
the lesion to its typical site in your
mind.
This
concept is helpful when diseases
present on atypical sites.
Palpation of Lesions
Simple palpation: to determine texture
Blunt pressure: to detect oedema, capillary refill, identify
the dermal defect in anetoderma.
Linear or shearing pressure: to elicit dermographism, or
Nikolsky’s sign in pemphigus
Squeezing or pinching: to determine depth
& consistency of lesions: pinching in scleroderma,
squeezing dermatofibroma lesion produces dimpling
Rubbing: release chemicals, e.g. rubbing a mastocytoma
causes urtication and a flare due to histamine release
(Darier’s sign)
Scratching and picking: scratching scale in psoriasis
makes scale appear more silver by introducing air–
keratin interfaces; more vigorous scratching produce
small bleeding points (Auspitz’s sign)
Investigations
1.
2.
3.
4.
5.
6.
Diascopy
Wood’s light
Tzanck smear
Dermoscopy
Confocal laser scanning microscopy
Biopsy
Diascopy
Gentle pressure on lesion with a glass
slide.
Lupus vulgaris: apple jelly nodules
Nevus anaemicus
Vitiligo
Spider nevi
Erythema vs purpura
Wood’s Light
This is a source of ultraviolet light from which virtually all
visible rays are excluded by a Wood’s (nickel oxide) filter
Uses:
1. Tinea capitis: green flourescence
2. Erythrasma: coral pink
3. Pityriasis versicolor: yellow
4. Scabies: put flourescin on lesion to visualize burrow
5. Porphyrias: teeth, urine, faeces and serum
flouresence
6. Ash leaf macules in tuberous sclerosis
Dermoscopy
Also known as epiluminescence microscopy, is
an extension of the simple magnification.
Dermoscopes have built-in illumination.
The oil is applied on the lesion to enhance
visibility of subcorneal structures. The lesion
examined with dermoscopes.
The technique is mainly used in the diagnosis
of doubtful pigmented lesions
Confocal laser scanning
microscopy
Digital Scanning Photography
SITE
Face:
Acne vulgaris.
lupus vulgaris
DLE
Melasma
Pitriasis alba.
Tuberous sclerosis.
BCC/SCC
Trunk:
Tinea.
Pitriasis
rosea.
Pitriasis versicolor.
Acne vulgaris
Psoriasis.
LIMBS
Pyoderma gangrenosum.
Erythema nodosum.
Erythema induratum.
Macules:
Pinpoint: lichen nitidus
Less than 0.5 cm: Macule
More than 0.5 cm: Patch
TYPE & SHAPE
Primary/secondary.
Flat.
Raised.
Raised & fluid containing.
PRIMARY RAISED LESIONS
Papule: less than 0.5 cm
Plaque: more than 0.5 cm
Nodule: larger with three dimensions
Papule
Less than 5mm.
round/oval/polygonal.
Colour: red, pink, purple, pigmented.
How to Diagnose a skin Disease
Papule/Plaque:
–Dome shaped: Psoriasis, Lichen planus
–Pointed: Keratosis pilaris, PRP
–Umblicated: Viral infections
–Well circumscribed plaques: Psoriasis
–Irregular plaques: Lupus vulgaris,
Shagreen patches
–Targetetoid: Stevens Jhonson synd
Plaque
Raised
More than 0.5cm.
Nodule
circumscribed
solid,
palpable,
Deep & indurated.
More than 0.5 cm.
PRIMARY RAISED & FLUID
CONTAINING LESIONS
Pustule.
Vesicle.
Cyst.
Bullae.
Wheal.
Pustules
Pus containing.
Circumscribed.
Less than 1cm.
Vesicle
Less than 1cm.
Containing clear fluid.
Cyst
More than 0.5cm.
May contain pus, blood, sabecous
secretions, mucous.
Bulla (blister)
Vesicle more than 0.5cm.
May be tense/tender.
Wheal
Transient edematous elevation.
Pink to pale in colour.
Cause by oedema of dermis &
capillary dilation.
How to Diagnose a skin Disease
Vesicular
Lesions
–All viral infections present as acute
vesicular lesions: e.g. Herpes Simplex,
Herpes zoster, Moll.Contagiosum
–Autoimmune blistering diseases
present as bullous eruption
–Acute irritant contact dermatitis
How to Diagnose a skin Disease
Purpuric
Lesions
Leukocytoclastic vasculitis
Henoch Schonlein purpura
Meningococcal meningococcemia
Drugs
How to Diagnose a skin Disease
Henoch Schonlein
purpura: palpabe
purpura on buttocks
SECONDARY LESIONS.
Crust.
Excoriation.
Lichenification.
Necrosis.
Scar.
Scaling.
Exfoliation.
Fissure.
Keratoderma.
Vegitations.
Erosions.
Ulcer.
Atrophy.
Sclerosis.
Crust
Dried exudate,
May be serous, prulent,
haemorrhagic.
Excoriation
Haemorrhagic excavation resulting
from scratching.
Lichenification
Thickening of skin with exagerated
skin creases.
Necrosis
Death of skin tissue usually black in
colour.
Scar
Final stage of healing of destructive
process.
Involve deeper dermis.
White, smooth, shiny.
Scaling
Desquamated horney flakes prduced
due to abnormal keratinization.
May dry, greasy.
Exfoliation
Splitting off of stratum corneum in
fine scales or sheets.
Fissure
Linear split or gap in skin surface.
Usually painful.
Keratoderma
Horney thickening of stratum
corneum.
May be congenital abnormality, or as
simple mechanical stimulation.
Vegitations
A growth Of pathological tissue
Consisting of multiple close set,
papillomatous masses.
Erosion
Partial break in the epidermis.
Heal with out scarring unless
secondary infected.
Ulcer
A full thickness loss of skin .
Heal by scarring.
Atrophy
Thinning & transparency of skin by
diminution of epidermis, dermis or
both.
Wrinkling & translucensy of skin
with Loss of skin marking.
Sclerosis
Circumscribed or diffuse hadening or
induration of the skin
Occur as a result of dermal or
subcutenous oedema cellular
infiltration or collagen proliferration.
Surface
Rough,eg seborrheic warts.
Smooth eg nelanocytic naevus.
Flat topped eg lichen planus.
Pointed eg miliaria rubra.
Mamilliated eg compound naevus.
Dome shape, umblicatted eg
molluscum contagiosum.
Colour
Pink in Eczema
Red in Psoriasis
Brown in Pityriasis versiclor.
Purple Papules in lichen planus.
Red papules in scabies.
Consistency
Firm in Dermatofibroma
Soft in Dermal mole.
Hard in secondary deposites.
Teethered in Scleroderma.
Margins
Discrete as in Psoriasis
Indistinct as in Eczema.
Activety more peripherally, with
central healing as in tinea, Lichen
planus.
Raised & rolled in BCC
Irregular in malignant melanoma.
Annular pattern
Can be
maular,
papular,
nodular.
Reticular arrangement
Net like arrangement
Livedo reticularis
Cutis marmorata
Erythema ab igne
Oral lesion in lichen planus