Download ppt

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.