Approach to a Dermatologic

Rapid assessment of tissue hydration

Physical Examination of the Skin

27, 2010
The diagnosis and treatment of dermatologic disease rests on AugustLift
a fold of skin and note ease with which it is moved (mobility)
the physicians ability to recognize the basic and sequential
& speed with which it returns to place (turgor)
lesions of the skin
Faster return means better hydration for the patient
Skin lesions: visible and accessible
Increase in turgor if it remains elevated
o Advantage: since it is accessible, an intervention such as a
Hair
biopsy can be performed easily
Facial,
axillary & pubic hairs dependent on presence of sex
o Disadvantage: There are thousands of skin diseases that
hormones,
thus, affected by sex & age of patient
for some (especially first-timers) would look the same
If with excessive hair, suggestive of endocrine disease
(thus, one must be keen enough to distinguish)
Alopecia areata - balding
Physicians: must learn to read skin for clues to underlying
systemic disease
Nails
** sometimes a history is no longer needed in order to make a
May provide a clue to certain systemic disease
diagnosis
o Psoriasis vulgaris (oil spots, onycholysis, loosening of nail,
crumbling of nail, little pits on nails)
Detailed Examination of the Integumentary System
Renal disease Half & half nails (proximal white & distal
Skin
pink/brown)
Hair
Hemochromatosis
Nails
o Spoon nails (koilonychia)
Mucous membranes

Due to faulty iron metabolism

Major Characteristics of Skin Lesions
Pulmonary, cardiac, hepatic & GIT disease
1. Color a factor of 4 pigments
o Clubbing (more common in cardiac diseases)
a. Melanin (brownish hue)
b. Oxyhemoglobin (reddish/erythematous hue)
Four Cardinal Features
c. Deoxyhemoglobin (bluish hue)
Type of Lesion
d. Carotene (yellowish hue)
Primary or Secondary
2. Consistency and feel of lesion(via palpation)
E.g., macule, papule, nodule, vesicle
Soft, doughy, firm, hard, infiltrated, dry, moist, mobile, tender
Shape and Arrangement of Lesions Provide Clues to the
Abnormalities in Skin Color
Diagnosis
Brownish Discoloration
Linear
Caf au lait spots (increased melanin production)
Phytodermatitis- plant dermatitis
o Neurofibrimatosis/von Recklinghausens Disease, von
Allergic reaction to plant particles usually seen in exposed areas
Hippel Lindau disease, McCune-Albright syndrome
of gardeners/housewives
Addisons disease (deposition of melanin in the mucous
Iris/Target
membrane)
bulls eye or iris lesions
Can be found in normal people
Erythema on periphery and central portion (papule or vesicle) of
discoloration violet or purple color
Bronze, Dark or Grayish Black Discoloration
Steven Johnsons Syndrome
Hemochromatosis
Pathognomonic of erythema multiforme
o Iron deposition in pancreas e.g., DM
Herpetiform
Yellow Skin Discoloration /Jaundice
Herpes simplex virus
Inc serum bilirubin
Annular / Ring like
o RBC hemolysis yellowish skin and sclera (most
Fungal infections
prominent discoloration)
Tinea capitis/ tinea corporis
Anemia
Arciform arc-like
o Yellow tinge sallow appearance
Polycyclic different shapes (seen in granuloma annulare - HIV)
o Best seen in areas where stratum corneum is thinnest
Grouped lesions xanthomas (cholesterol deposits that can be
(nails, lips, mucous membrane & palpebral conjunctiva)
yellowish or reddish)
Round
Hypopigmentation - Vitiligo
Oval
Acquired /autoimmune loss of melanin pigment
Vesicles in a band on dermatome/ zosteriform
Related to other autoimmune diseases such as Hashimotos
Herpes
zoster
Thyroiditis, hyperthyroidism, DM, pernicious anemia
Only one side of body
Chalk-white discoloration
50-70%- found in trunk
Erythema (Redness)
Multiple coalescing vesicles; erythematous lesion
Increased cutaneous flow
Umbilicated looks like an umbilicus (presence of indentation in
Most commonly a component of inflammation
the middle part
o E.g., Drug eruption, viral exanthema (with fever, malaise,
Distribution
joint pains, lymphadenopathy)
Extent of involvement circumscribed, regional, generalized,
o To distinguish obtain drug intake history (2-4 weeks)
universal (*generalized entire body)
Drugs that may cause Discoloration
What percent of the body surface is involved? (entire palm is
Clofazimin (Leprosy drug)
roughly 1%)
o Dark brown
Pattern symmetry, exposed areas, sites of pressure,
o Main lesion discoloration
intertriginous areas
Quinacrine (antimalarial)
o * pressure urticaria
o Yellow
o * intertriginous fungal/candidal infections axillary,
Amiodarone (antihypertensive, antiarrhythmic)
intramammary, inguinal areas
o Bluish
Characteristic location
Minocycline (for severe acne)
o Flexural e.g., childhood atopic dermatitis
o Bluish
o Extensors
o Intertriginous areas
o Glabrous areas without hair
Turgor
o Palms and soles (e.g., scabies)

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o
o
o
o

Dermatomal
Trunks
Lower extremities
Exposed areas

Basic/Primary Skin Lesions

- Most of the time, patient does not have basic lesion
anymore due to late consultation
Macule
Circumscribed, flat lesion
o Differs in color
Size < 1 cm
Any shape
Sometimes with fine scaling:
o Maculosquamous
Hyperpigmented Ephelides/freckles
Tinea vesicolor
freckles, flat moles, tattoos, port-wine stains, and the
rashes of rickettsial infections, rubella, measles, and
some allergic drug eruptions
Patch
Circumscribed, flat lesion
Size > 1cm
Any shape
Fine scaling
Is a large macule (coalescence of many macules)
E.g., vitiligo
Papule
Small (<1 cm), solid elevated lesion
Projects above plane of skin
Variety of shapes (dome [milia], flat-topped)
nevi, warts, lichen planus, insect bites, seborrheic and
actinic
Plaque
Mesa-like elevation that occupies larger surface area than
height
>1cm
May be formed by confluence of papules
Lichenification: due to rubbing (kalyo?)
Psoriasis vulgaris and granuloma annulare
Nodule
Palpable, solid, round/oval lesion
Deeper than papule
o Depth (not diameter) distinguishes it from papule
o Hard, soft, movable, fixed, etc
Neurofibromatosis
nevi, warts, lichen planus, insect bites, seborrheic and
actinic
Wheal
Hives/uticaria
o Evanescent flat/ rounded papule or plaque, pink
(evanescent meaning can travel from one location to
another within 24 hours)
o Epidermis- unaffected

o
o
o
o
o

Borders unstable
Allergic response
dermographism when there is scratching an
elevated lesion will occur at the site due to
histamines effect on the skin
Warm
Skin asthma, ectopic dermatitis

Vesicle
0.5 - <1cm
Circumscribed lesion that contains fluid
Herpes simplex lesions, dermatitis, dyshydrophic eczema
Arise from cleavage at various skin levels
Bulla
> 0.5 1cm, contains fluid
Burns, insect bites (for allergic patients); pemphigus
vulgaris (autoimmune disease, needs high dose of
corticosteroids)
Pustule
Hallmark of infection
Circumscribed raised lesion with purulent exudates
Pus
o Leukocytes, cellular debris
Furuncle (deep necrotizing folliculitis)
o Deep necrotizing folliculitis
Carbuncle
o Coalescing furuncles
*folliculitis furuncle carbuncle
* increase incidence of folliculitis during the summer heat
aggravates Staph infections
Secondary Lesions
Crust
Results when serum, blood or purulent exudates dries on
the skin surface
Characteristic of injury & pyogenic infections
o Yellow dried serum
o Green/ yellow green purulent exudates
o Brown/ dark red- blood
o Honey-colored impetigo
Fissure
Linear cleavages or cracks in the skin
Painful
Anal; angles of mouth, heels
Excoriation
Superficial excavations of epidermis
May be linear or punctuate
Result from scratching
Atopic dermatitis (childhood 2-7 years old)
Lichenification
Thickening of the skin as a consequence of persistent,
prolonged, vigorous rubbing
Accentuation of normal skin markings
Hyperpigmentation

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Induration
E.g., Lichen Simplex Chronicus
Erosion
Moist circumscribed lesion resulting from loss of epidermis
Rupture of vesicles and bullae
Do not scar unless infected
Atrophy
Diminution or thinning of the skin
Scleroderma autoimmune
Stria Gravidum
Ulcer
Hole or defect that remains after an area of epidermis and
part of dermis is destroyed
Dermis heals with scarring
Venous ulcer medial mallelous; presents with varocities in
upper legs
Decubitus ulcers in prolonged immobility/bedrest
Scar
Fibrous tissue replacement
Consequence of healing at site of prior ulcer or wound
Hypertrophic or atrophic
Hypertrophy remain in the area
Keloid claw-like spread to adjacent areas
Atrophic depression
Scales
Abnormal shedding or accumulation of epidermis in
perceptible flakes
Psoriasis
Keratotic plug upper arm and thigh
o Pityriasiform branny
o Psoriasiform micaceous
o Icthyosiform fish scales
o Keratotic horny masses
o Follicular keratotic plugs
Clinical Tests
Dimple Sign
Dermatofibroma
Apply pressure feels like a button/depression [(+) test]
Nikolskys sign
Sheetlike removal of epidermis by gentle traction
positive when slight rubbing of the skin results in exfoliation
of the skin's outermost layer and gravitation of fluid
towards the opposite side
if intradermal (+); if subdermal (-)
Pemphigus vulgaris/ TEN
Dariers sign
Development of urticarial wheel in uticaria pigmentosa
Stroking of skin development of urticaria
Auspitz sign
Pinpoint bleeding after removal of scale in psoriasis
Additional Slides: (Puro pictures to e, kaso di nya binigay
ppt..)

Leprosy tuberculoid only one lesion

Chicken pox vesicle umbilicated ulcerated
Foot, Hand , Mouth Disease- viral lesion
Herald Patch
Tinea capitis dirty looking scalp
General P.E.
Indicated by clinical presentation and differential diagnosis
Pay particular attention to vital signs, lymphadenopathy,
hepatomegaly, splenomegaly
Summary
Dermatological diagnosis is based primarily on visual
inspection
o Use magnifying glass, oblique lighting and woods
lamp
Palpation, diascopy, scratching of lesions
o Provides further clues
Combine PE with clues from the history to come up with
diagnosis
Approach to Dermatologic Patient
There are hundreds of cutaneous disease
A disease entity may have different clinical appearances
Skin diseases are dynamic and may evolve in morphology
Obtain a brief history from the patient
NOTE:
o Duration when did it start?
o Rate of onset how did it start?
o how have lesions changed?
o Location where did it start?
o how did it spread?
Brief History
Previous episodes has something similar occurred
before?
Family history
Allergies, medical history
Occupation,, hobbies, travel, exposure
Previous treatments
Review of systems
Determine the extent of the eruption by having the patient
disrobe completely under good lighting
Determine the primary lesion
Determine the nature of the secondary lesion
Determine the distribution of the lesion
Formulate a differential diagnosis
Special Procedure
Skin Biopsy
o Punch biopsy disposable
o 2-10mm diameter
o Punch thru layers, making sure to include all up to fat
area
o Apply local anesthetic
Gram stain

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o Crusts, scales, exudates

Potassium hydroxide examination
o For yeast and fungi
o 10% KOH causes separation of epidermal cells,
allows visualization of hyphae/spores
o Tinea versicolor spaghetti and meatballs
appearance
Tzanck smear
o Vesicular and bullous lesions
o Direct smear of the floor of lesion to look for giant
multinucleated cells
Woods light examination
o Filtered UV light
o Urine-porphyria

Hair and skin changes in pigmentation,

fluorescence
Patch tests
o Document sensitivity to a substance or antigens
Diascopy
o Differentiates vasculitis(blanching absent) from
erythema (blanching present)
o

References:
Lecture and Notes from Dr. Medel
Ultimate Mafia Trans
Trans by: Relloras, Revelo, Reyes

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