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The Fundamentals of Dermatologic Diagnosis Mary E. Hurley, MD Clinical Instructor, UTSW Private Practice, Presbyterian Hospital Dallas What is most difficult of all? It is what appears most simple: to see with your eyes what lies in front of your eyes. Goethe General Observation Start gathering data the moment you walk in the room Ask yourself the following questions – Is the patient awake, alert, and responsive? well appearing? acutely ill appearing? chronically ill appearing? in distress or uncomfortable? uncomfortable child with atopic dermatitis History and Review of Systems Make sure you ask appropriate questions in the history and review of systems. – – – – – – – – What is the location of the problem? How long have they had the problem? Does is itch? Is it painful? What makes it better or worse? What treatments have they tried? Is the patient on any medicines? Does the patient have a family history of skin disease or skin cancer? The Skin Exam Perform a total body skin exam in a systematic and deliberate manner. – – This includes the entire skin surface, the hair, the nails, the conjunctiva, and the oral and genital mucosa. Ideally, the patient would remove undergarments and wear an examination gown only. The Skin Exam Be sure to examine the oral mucosa! Oral erosion in SLE. The Skin Exam Melanoma can appear anywhere. If you don’t look, you will miss it, and the patient may miss an opportunity for therapy. The Skin Exam Examination of the skin is an essential part of a thorough patient encounter. Observation and palpation are the two most important aspects of the skin exam. – Please seek to examine a patient’s entire skin surface. – Patient wearing a gown Preserve modesty Good lighting is essential. Natural light is optimal. The Skin Exam Specific language used to describe the characteristics of skin lesions Distribution Arrangement Type of lesion – Primary lesion – Secondary lesion Color Features based on touch/palpation Distribution Generalized vs localized Exposed vs non-exposed Sun-exposed vs non-sun-exposed Acral (head, neck and extremities) vs truncal Extensor (posterior arms, anterior legs) vs flexor (anterior arms, posterior legs) surfaces Bilateral vs unilateral Upper vs lower extremity Dermatomal (following the distribution of a spinal nerve root) Hair-bearing (non-glabrous) vs non-hair-bearing (glabrous) skin Follicular vs perifollicular vs non-follicular Seborrheic (areas with high concentrations of sebaceous glands: e.g. brows, nasolabial folds) Facial, periocular, perioral Intertriginous (areas where skin folds on itself) Mucous membrane Sites of pressure Sites of trauma (koebnerization) Palmo-plantar Periungual (around the fingernails) Sun Exposed malar rash of acute cutaneous lupus symmetric and generalized dermatomal following the distribution of a spinal nerve root atopic dermatitis involving flexoral areas nickel dermatitis from earring Arrangement Isolated Scattered Grouped – Herpetiform (random grouping) – Zosteriform (grouping in dermatomes) Circular – Annular (complete ring) – Arciform (incomplete ring) – Polycyclic (multiple rings) Linear Angular Reticulated or mat-like Grouped (herpetiform) herpes simplex infection Grouped (zosteriform) herpes zoster Annular (complete ring) pustular psoriasis subacute cutaneous lupus Linear Psoriasis Type of lesion Primary lesion Macule - Non-palpable lesion with distinct borders, less than 1 cm in diameter Patch - Non-palpable lesion with distinct borders, greater than 1 cm in diameter Papule – Palpable, solid lesion less than 1 cm in diameter Plaque – Palpable, solid lesion greater than 1 cm in diameter Nodule – Palpable, lesion more than 1 cm in diameter which is taller than it is wide Vesicle – Fluid-containing, superficial, thin-walled cavity less than 1 cm Bulla – Fluid-containing ,superficial, thin-walled cavity greater than 1 cm Erosion – A skin defect where there has been loss of the epidermis only Ulcer – A skin defect where there has been loss of the epidermis and dermis Pustule – Pus containing, superficial, thin-walled cavity Abscess – Thick-walled cavity containing pus Macule: Non-palpable change in skin color with distinct borders Macule: Non-palpable change in skin color with distinct borders Patch: Non-palpable change in skin color with distinct borders Papule: Palpable, solid lesion less than 1 cm in diameter Papule: Palpable, solid lesion less than 1 cm in diameter Papule: Palpable, solid lesion less than 1 cm in diameter blue nevus Plaque: Palpable, solid lesion greater than 1 cm in diameter Plaque: Palpable, solid lesion greater than 1 cm in diameter psoriasis Plaque: Palpable, solid lesion greater than 1 cm in diameter urticaria Vesicle: Fluid-containing, superficial, thin-walled cavity less than 1 cm Vesicle: Fluid-containing, superficial, thin-walled cavity less than 1 cm Vesicle: Fluid-containing, superficial, thin-walled cavity less than 1 cm varicella with vesicles and bullae Nodule: Palpable, lesion more than 1 cm in diameter which is taller than it is wide Nodule: Palpable, lesion more than 1 cm in diameter which is taller than it is wide neurofibromatosis with multiple papules and nodules Nodule: Palpable, lesion more than 1 cm in diameter which is taller than it is wide Bulla: Fluid-containing ,superficial, thin-walled cavity greater than 1 cm Bulla: Fluid-containing ,superficial, thin-walled cavity greater than 1 cm bullous pemphigoid Erosion: A skin defect where there has been loss of the epidermis only Erosion: A skin defect where there has been loss of the epidermis only toxic epidermal necrolysis Ulcer: A skin defect where there has been loss of the epidermis and dermis Ulcer: A skin defect where there has been loss of the epidermis and dermis pyoderma gangrenosum Pustule: Pus containing, superficial, thin-walled cavity www.medstudents.com Pustule: Pus containing, superficial, thin-walled cavity Inflammatory acne Pustule: Pus containing, superficial, thin-walled cavity pustule over joint in disseminated gonococcemia Abscess: Thick-walled cavity containing pus Abscess: Thick-walled cavity containing pus Secondary Lesions: changes in skin which are superimposed or are the consequence of the primary process – – – – – – – Scale - desquamating layers of stratum corneum. Crust- dried serum, blood or purulent exudate. Crusts are a sign of pyogenic infection. Lichenification - skin thickening that is the result of chronic rubbing leading to accentuation of normal skin lines. Atrophy- epidermal atrophy results from a decrease in the number of epidermal cell layers. Dermal atrophy results from a decrease in the dermal connective tissue. Scar- a lesion formed as a result of dermal damage. Excoriation - superficial excavations of the epidermis that result from scratching. Fissure - a linear painful crack in the skin. Scale: desquamating layers of stratum corneum Fungal infection Crust: dried serum, blood or purulent exudate Crusts are a sign of . pyogenic infection impetigo with honey colored crust Atopic dermatitis with lichenification Lichenification – skin thickening that is the result of chronic rubbing leading to accentuation of normal skin lines. Atrophy – – Epidermal atrophy results from a decrease in the number of epidermal cell layers. Dermal atrophy results from a decrease in the dermal connective tissue. Scar Scar- a lesion formed as a result of dermal damage. Excoriation: –superficial excavation of the epidermis that results from scratching linear excoriations in a patient with atopic dermatitis Color Skin- or flesh-colored Hypopigmented vs hyperpigmented White Brown Grey Black Red Blue Violaceous Dark purple (purpura) Yellow Orange Green Erythematous Hyperpigmented Melanoma with regression Black Brown White Red Argyria Blue-Gray Violaceous skin lesions of dermatomyositis Purpura palpable purpura The Skin Exam Observe the patient’s skin color. – Substances contributing to the skin’s color include: melanin (brown) and carotenoids (yellow) in the epidermis oxyhemoglobin (red, located in arterial plexus) and reduced hemoglobin (bluish-red, located in the venous plexus) in the dermis increased pigmentation may suggest Addison’s disease or metastatic melanoma – yellow color may suggest jaundice from liver disease – cyanosis or a bluish color to the lips may suggest hypoxia – The Skin Exam yellow coloration of sclerae in patient with liver disease The Skin Exam Palpate and observe the patient’s skin for level of moisture, temperature, texture, mobility and turgor. – – – – dry, rough skin may suggest hypothyroidism moist, warm skin may suggest an underlying febrile illness or hyperthyroidism excoriations may suggest a pruritic skin eruption such as scabies or an underlying systemic disease such as lymphoma tight, bound-down skin over the hands or face may suggest a diagnosis of scleroderma Features based on touch or palpation Consistency – soft, doughy, rubbery, firm, hard Dry vs wet Fixed vs mobile Presence or absence of tenderness Surface characteristics – smooth, velvety, pebbled The Skin Exam Metastatic breast cancer must be PALPATED to be fully appreciated. Nodule Rubbery, Mobile, Non-tender Melanoma metastases Firm, Fixed, Nodules sclerodactyly Cellulitis Erythematous, Tender, Warm to touch Abscess Tender, Fluctuant, Warm Wet, Tender, Ulcerated Dry Consider the use of diagnostic aids Magnify the lesions with a hand lens or using epiluminescence microscopy (using a hand lens with magnification and lighting built in to better visualize lesions). Consider the use of diagnostic aids Use a wood’s lamp (long wavelength ultraviolet light) to examine if a lesion is hypo or depigmented or to see if a fungal infection fluoresces. Consider the use of diagnostic aids Use diascopy (press a transparent, firm object such as a glass slide against a lesion) to determine if an erythematous lesion blanches. – – If the lesion blanches or loses its erythematous color, this suggests that the erythema is due to capillary dilation. If the lesion does not blanch or lose its red color, this suggests that the erythema is due to extravasation of blood (this can result from vasculitis or destruction of the vessel wall). Consider the use of diagnostic aids apple jelly color with diascopy of cutaneous sarcoid References Bickley LS, Hoekelman RA. Physical Examination: Approach and Overview, The General Survey, The Skin. In: Bickley LS, Hoekelman RA, editors. Bates Guide to Physical Examination and History Taking. Philadelphia: Lippincott Williams and Wilkins; 1999. p. 129-161. Stewart MI, Bernhard JD, Cropley TG, Fitzpatrick TB. The Structure of Skins Lesions and Fundamentals of Diagnosis. In: Freedberg IM, Eisen AZ, Wolff K, et al, editors. Fitzpatrick’s Dermatology in General Medicine 6th Edition. New York: McGraw-Hill; 2003. p. 11-30. Bolognia JL, Jorizzo JL, Rapini RP. Dermatology. Spain: Elsevier Limited; 2003.