Transcript History of a rash Key questions

Dermatological History and
Examination
History of a rash
• Key questions:
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When did it start?
Does it itch, burn, or hurt?
Where on the body did it start?
How has it spread (pattern of spread)?
How have individual lesions changed (evolution)?
Aggravating factors?
Previous treatments and response?
History of a growth
• Key questions:
– How long has the lesion been present?
– Has it changed, grown, bled, itched, or failed to
heal?
• General history of present illness as indicated
by clinical situation
– Acute illness syndrome (fever, sweats, chills,
headache, nausea, vomiting, cough, runny nose,
etc.)?
– Chronic illness syndrome (fatigue, anorexia,
weight loss, malaise)?
• Review of systems
– particular attention to symptoms indicating a
possible connection between cutaneous signs and
disease of other organ systems
• Review of systems for growths suspicious for,
or associated with, malignancy:
– particular attention to symptoms of metastasis
(weight loss, fevers, chills, night sweats, headache,
swollen glands, abdominal pain, abnormal
stooling, bone pain, etc.)
Medication history
• All prescription, nonprescription, and
"complementary" medications, with particular
attention to those that temporally correspond
to the onset of the eruption
• Allergies
Past medical history
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Illnesses
Operations
Atopic history (asthma, hay fever, eczema)
Family medical history, particularly of skin disorders
and of atopy
• Family history of skin, or other, cancers
• Social history with particular reference to occupation,
hobbies, sun exposure, pet exposure, tobacco smoking,
alcohol consumption, recreational drugs, travel, sexual
orientation and exposures
Examination
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General Inspection: Does the patient appear ill?
Physical examination: detailed examination of the skin, hair, nails, and mucous
membranes
Important features of a skin lesion:
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Type of lesion: macule, papule, nodule, vesicle, etc. (see Table 4-2 below)
Shape of individual lesions: annular, iris, arciform, linear, round, oval, umbilicated, etc.
Arrangement of multiple lesions: isolated, scattered, grouped, linear, etc.
Distribution (be sure to examine scalp, mouth, palms, and soles)
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Extent of involvement: circumscribed, regional, generalized, universal? What percentage of the body
surface is involved?
Pattern: symmetry, exposed areas, sites of pressure, intertriginous areas?
– Color
– Consistency and feel of lesion: soft, doughy, firm, hard, "infiltrated," dry, moist, mobile,
tender, warm?
– Anatomic components of the skin primarily affected: Is the process epidermal, dermal,
subcutaneous, appendageal, or a combination of these?
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General physical examination as indicated by the clinical presentation and
differential diagnosis, with particular attention to vital signs, lymphadenopathy,
hepatomegaly, splenomegaly, joints, etc.
Papule
• A papule is a solid,
elevated lesion < 0.5
cm in size
Papule. Multiple, well-defined papules of varying
sizes are seen. Flat tops and glistening surface are
characteristic of lichen planus
Plaque
• A plaque is a solid
plateau-like elevation
that has a diameter >
0.5 cm
Plaque. Well-demarcated pink plaques with a
silvery scale representing psoriasis vulgaris.
Nodule
• On the skin, a nodule is
a solid, round or
ellipsoidal, palpable
lesion that has a
diameter > 0.5 cm.
• Depth of involvement
and/or substantive
palpability, rather than
diameter, differentiates
a nodule from a large
papule or plaque.
Nodule. A nodular
BCC with welldefined, firm nodule
with a smooth and
glistening surface
through which
telangiectasia can be
seen.
Cyst
• A cyst is an encapsulated
cavity or sac lined with a
true epithelium that
contains fluid or semisolid
material (cells and cell
products such as keratin).
• Spherical or oval shape
• Depending on the nature
of the contents, cysts may
be hard, doughy, or
fluctuant.
• A clinical example is a
cystic hidradenoma
Cyst. A bluish colored resilient cyst filled with a
mucous-like material on the cheek is a cystic
hidradenoma
Wheal
• A wheal is a swelling of the skin
that is characteristically transient,
disappearing within hours.
• Also known as hives or urticaria
• It is the result of oedema
produced by the escape of
plasma through vessel walls in
the upper portion of the dermis.
• Wheals:
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Variable size
Variable shapes
Borders are sharp but not stable
Pink to pale red in colour.
Soft to firm depending on the
extent of oedema present.
• A clinical example is
dermatographism
Wheal. A sharply demarcated wheal with a
surrounding erythematous flare occurring within
seconds of the skin being stroked.
Ulcers
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An ulcer is a defect in which the
epidermis and at least the upper
dermis has been removed.
– Location of the ulcer, such as on the
medial aspect of the ankle or over
pressure points, may be telling
– Borders of the ulcer may be rolled,
undermined, punched out, jagged, or
angular
– The base may be clean, ragged, or
necrotic
– Discharge may be purulent, granular, or
malodorous
– Surrounding skin may be red, purple,
pigmented, reticulated, indurated,
sclerotic, or infarcted
– Other informative features include the
presence of nearby nodules,
surrounding excoriations, varicosities,
hair, sweat, and the strength of
Ulcer. A large ulcer with a ragged base and
adjacent pulses.
heaped up pink erythematous border on the
leg .
Atrophy
• Atrophy refers to a
diminution in the size of a
cell, tissue, organ, or part of
the body.
• A decrease in the number
of epidermal cells results in
thinning of the epidermis.
• Atrophic epidermis is glossy,
almost transparent, paper
thin and wrinkled, and may
not retain normal skin lines.
Atrophy. Thin,
wrinkled
atrophic skin
that has lost its
normal texture
on the arm of
this elderly
woman
Striae
• Striae are linear depressions
of the skin that usually
measure several
centimeters in length and
result from changes to the
reticular collagen that occur
with rapid stretching of the
skin.
• The surface of striae may be
thin and wrinkled.
• They may be pink to red in
color and raised before
becoming paler and
flattened out.
Striae. Linear striae on the back of this woman
who experienced a rapid growth spurt and
weight gain.
Sclerosis
• Sclerosis refers to a circumscribed
or diffuse hardening or induration
in the skin that is a result of
dermal fibrosis.
• It is detected more easily by
palpation, on which the skin may
feel board-like, immobile, and
difficult to pick up.
• Hyperpigmentation or
hypopigmentation may also
distinguish the area of induration
from normal skin.
• The epidermis overlying sclerotic
dermis may be atrophic.
Sclerosis. Firm, slightly depressed sclerotic
plaque on the leg of a girl with morphea. The
surface is atrophic and there are areas of hypoand hyperpigmentation.
Flat and Macular Lesions
• A macule is a flat lesion, even
with the surface level of
surrounding skin, perceptible
as an area of colour different
from the surrounding skin or
mucous membrane.
• Macules are non-palpable.
• Their shapes are varied and
borders may be distinct or
vague.
• Perhaps the most important
additional feature of a lesion
other than primary
morphology is color.
Macule. Uniform colored brown macule with
slightly irregular, sharply defined borders
representing a lentigo on the lip
Erythema
• Erythema represents the
blanchable change in
colour of skin or mucous
membrane that is due to
dilatation of arteries and
veins in the dermis.
• It exists in different
colours, and to dub a
primary lesion as
erythematous alone is
incomplete.
Erythema. A large area of dusky red erythema
in the gluteal region representing a fixed drug
eruption.
Scale, Desquamation (Scaling)
• A scale is flat plate or
flake arising from the
outer-most layer of the
stratum corneum.
Scale. Brittle silvery scales forming thin
platelets in several loose sheets, on this plaque
of psoriasis
Crusts
• Crusts are hardened
deposits that result when
serum, blood, or purulent
exudate dries on the surface
of the skin.
• The colour of crust is a
yellow-brown when formed
from dried serous secretion;
turbid yellowish-green
when formed from purulent
secretion; and reddish-black
when formed from
Crust. Glistening, honey-colored, delicate
hemorrhagic secretion.
crusts under the nose representing impetigo.
Excoriations
• Excoriations are surface
excavations of epidermis
that result from scratching
and are frequent findings in
patients experiencing
pruritus.
• Rigorous or uncontrollable
scratching may produce
long, parallel, sometimes
crossing, groups of
excoriations which may be
hemorrhagic when light
Excoriation. Linear and punctate excoriations
bleeding is induced.
on the back induced by scratching.
Lichenification
• Repeated rubbing of the
skin may induce a
reactive thickening of the
epidermis, with changes
in the collagen of the
underlying superficial
dermis.
• These changes produce a
thickened skin with
accentuated markings,
which may resemble tree
bark.
Lichenification. An area of thickened skin with accentuated
skin markings induced by repeated rubbing, representing
lichenification noted in lichen simplex chronicus.
Keratoderma
• Keratoderma is an
excessive hyperkeratosis
of the stratum corneum
that results in a yellowish
thickening of the skin,
usually on the palms or
soles, that may be
inherited (abnormal
keratin formation) or
acquired (mechanical
Lichenification. An area of thickened skin with
stimulation).
accentuated skin markings induced by
repeated rubbing, representing lichenification
noted in lichen simplex chronicus.
Eschar
• The presence of an eschar
implies tissue necrosis,
infarction, deep burns,
gangrene, or other
ulcerating process.
• It is a circumscribed,
adherent, hard, black
crust on the surface of
the skin that is moist
initially, protein rich, and
avascular.
Eschar.
Overlying
eschars
compromisin
g peripheral
perfusion in a
burn victim.
Fluid-Filled Lesions
• Vesicle and Bulla
– A vesicle is a fluid-filled cavity
or elevation smaller than or
equal to 0.5 cm, whereas a
bulla (blister) measures larger
than 0.5 cm.
– Because of their size, bullae are
easily identifiable as tense or
flaccid weepy blisters.
– Once collapsed or torn, blisters
may leave behind erosions.
– The cavity wall is often thin and
translucent enough to allow
the visualization of contents,
which may be clear, serous,
hemorrhagic, or pus filled.
Vesicle (A) and bulla (B).
Fragile sub-corneal
translucent vesicles
representing impetigo
caused by a toxin-producing
staphylococcus (A) and
large tense sub-epidermal
bullae filled with serous or
hemorrhagic fluid in this
patient with bullous
pemphigoid (B).
Pustule
• A pustule is a circumscribed,
raised cavity in the epidermis
containing pus.
• The purulent exudate,
composed of leukocytes with
or without cellular debris, may
contain bacteria or may be
sterile.
• Depending on its sterility, the
exudate may be white, yellow,
or greenish-yellow in color.
• Because of their superficial
location, pustules generally
heal without scarring.
Abscess
• An abscess is a localized
accumulation of
purulent material in the
dermis or subcutaneous
tissue.
• An abscess is a pink
erythematous, warm,
tender, fluctuant nodule
that may be associated
with other signs of
infection such as fever.
Abscess. A tender red erythematous fluctuant
abscess on the leg.
Purpura/Vascular Lesions
• Extravasation of red blood from
cutaneous vessels into skin or
mucous membranes results in
reddish-purple lesions included
under the term purpura.
• Petechiae are small, pinpoint
purpuric macules.
• Ecchymoses are larger, bruise-like
purpuric patches.
• These lesions correspond to a
noninflammatory extravasation of
blood.
• As extravasated red blood cells
decompose over time, the color
of purpuric lesions change from
bluish-red to yellowish-brown or
green.
Purpura. Nonblanching red
erythematous
papules and
plaques
(palpable
purpura) on the
legs,
representing
leukocytoclastic
vasculitis.
Telangiectasia
• Telangiectasia are
persistent dilatations of
small capillaries in the
superficial dermis that
are visible as fine,
bright, nonpulsatile red
lines or net-like patterns
on the skin.
Telangiectasia. Blanching dilated superficial
capillaries representing telangiectasia.
Shape or Configuration of Skin Lesions
• Annular: ring-shaped;
implies that the edge of
the lesion differs from
the centre, either by
being raised, scaly, or
differing in colour
• Round/nummular/disco
id : coin-shaped; usually
a round to oval lesion
with uniform
morphology from the
edges to the center
• Polycyclic: formed from
coalescing circles, rings,
or incomplete rings
• Arcuate: arc-shaped;
often a result of
incomplete formation
of an annular lesion
• Linear: resembling a
straight line
• Reticular: net-like or
lacy in appearance, with
somewhat regularly
spaced rings or partial
rings and sparing of
intervening skin
• Serpiginous: serpentine
or snake-like
• Targetoid: target-like,
with at least three
distinct zones
Distributions of Multiple Lesions
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Dermatomal/zosteriform: unilateral and lying in the distribution of a single spinal afferent nerve
root; the classic example is herpes zoster.
Blaschkoid (Fig. 4-47): following lines of skin cell migration during embryogenesis; generally
longitudinally oriented on the limbs and circumferential on the trunk, but not perfectly linear
(see also Whorled in Shape and Configuration of Lesions); described by Alfred Blaschko and
implies a mosaic disorder (e.g., incontinentia pigmenti, inflammatory linear verrucous epidermal
nevus).
Lymphangitic: lying along the distribution of a lymph vessel; implies an infectious agent that is
spreading centrally from an acral site, usually a red streak along a limb due to a staphylococcal
or streptococcal cellulitis.
Sun exposed: occurring in areas usually not covered by clothing, namely the face, dorsal hands,
and a triangular area corresponding to the opening of a V-neck shirt on the upper chest (e.g.,
photodermatitis, subacute cutaneous lupus erythematosus, polymorphous light eruption,
squamous cell carcinoma).
Sun protected: occurring in areas usually covered by one or more layers of clothing; usually a
dermatosis that is improved by sun exposure (e.g., parapsoriasis, mycosis fungoides).
Acral: occurring in distal locations, such as on the hands, feet, wrists, and ankles (e.g.,
palmoplantar pustulosis, chilblains).
Truncal: occurring on the trunk or central body.
Extensor: occurring over the dorsal extremities, overlying the extensor muscles, knees, or
elbows (e.g., psoriasis).
Flexor: overlying the flexor muscles of the extremities, the antecubital and popliteal fossae (e.g.,
atopic dermatitis).
Intertriginous: occurring in the skin folds, where two skin surfaces are in contact, namely the
axillae, inguinal folds, inner thighs, inframammary skin, and under an abdominal pannus; often
related to moisture and heat generated in these areas (e.g., candidiasis).
Localized: confined to a single body location (e.g., cellulitis).
Generalized: widespread. A generalized eruption consisting of inflammatory (red) lesions is
called an exanthema (rash). A macular exanthema consists of macules, a papular exanthema of
papules, a vesicular exanthema of vesicles, etc. (e.g., viral exanthems, drug eruption).
Bilateral symmetric: occurring with mirror-image symmetry on both sides of the body (e.g.,
vitiligo, plaque-type psoriasis).
Universal: involving the entire cutaneous surface (e.g., erythroderma, alopecia universalis).