1. BCS LCD Efloresensi dr. PS.ppt

8/20/2019 1. BCS LCD Efloresensi dr. PS.ppt

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dr. NM Dwi Puspawati, SpKKBag/SMF I. Kes. Kulit & KelaminFK Unud/RS Sanglah Denpasar


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The art of Diagnosis in General :

• Anamnesis

• Physical Examination

• Laboratory finding

Detailed systematic history with good physicalexamination, supplemented by appropriate laboratory

test will be the golden rule for the correct approach inthe diagnosis


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GENERAL HISTORY

! "ace, geographical

#! $ocial bac%ground, ethnic tradition, dietary habits

&! Past medical history : allergy to medication, hay fe'er,asthma, past ma(or illness or operation

)! $ocial * occupational history: tra'el abroad, hobbiesand details of the type of wor%, substances in contact


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History of present illness : duration, date * site of onset,details of spread, e'olution of rash * original morphology,symptoms such as itchiness, pain, burning sensation, numbness,precipitating and relie'ing factors such as climate, sunlightetc!, treatment +topical * systemic medication sought or

applied

Past history of skin disorders : history of sunburn

Faily history of skin disorders : e!g! s%in cancers and atopicdisorders-stigmata atopic

!r"#s : include herbs, topical, systemic, patient initiated orphysician prescribed! Patient.s own perception on the cause ofthe problem

SPE$IAL HISTORY


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E%A&INATION OF S'IN


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! Ade/uate pri'acy

#! Good lighting

&! $patula, magnifying glass and transparent glass slide fordiascopy

0t is a good practice if affordable to ha'e thoroughexamination of the whole body especially for newconsultation and for the elderly

$ometimes, examination of the bac% and buttoc% of the

elderly may pic% up unexpected lesions, e'en the patienthimself or herself may not notice them e!g! persistentchronic annular erythematous rash in the buttoc% found ina case of tuberculoid leprosy


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Do not s%ip examination of the nail, scalp and oral mucous

membrane because there may be 'aluable clues, find theatopic stigmata

0n dermatology : uni/ue of physical examination by the'isual of the s%in and the s%in lesions E11L2"E$3E43E

Good and clear description of s%in lesion can be diagnosedof some s%in disease with a high degree of confidence


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EFFLORES$EN$E :A s%in lesion is an abnormal growth or an area of s%in that

does not resemble the s%in surrounding it +normal s%in2b(ecti'e appearance

!ETAIL !ES$RI(E! OF S'IN LESION :!Type of s%in lesion#!3haracteristic of lesion : colour, multiple or soliter,shape, margin, si5e, surface characteristics, temperatureand smell

&!Arrangement and configuration)!Distribution


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)* Type of skin lesion :!! Primary lesion :•

6acula• Papule• Pla/ue• 7esicle• Pustule

!#! $econdary lesion :• $cale•

3rust• 8lcer• Erosion• Excoration

•

4odul• 8rtica• 9ula• 3yst

• Lichenification• Atrophy• $car• 1issure


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#! $hara+teristi+ of skin lesion :

• 3olour salmonpin%, erythematous,

hyperpigmented, s%in colour, yellow• 6ultiple or soliter

• $hape geometric shape, o'al

• 6argin sharpness of edge, welldefined, illdefined

• $i5e diameter, punctata, numuler

• $urface characteristics domeshaped, umbilicated,

spi%e li%e• Temperature and smell warm on palpation, mousyodor


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&! Arran#eent and +onfi#"ration :• Grouped as in dermatitis herpetiformis, herpessimplex, common warts• Annular or arciform as in granuloma annulare, mycosis

fungoides, tinea circinata, erythema annularecentrifugum• Linear pattern as in lichen planus, lichen striatus,morphoea, lichen sclerosis, phytophotodermatitis


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,* !istri-"tion :•

symmetrical, asymmetrical• exposed area, sun exposed area• scalp region, hand• extensor aspect, flexor aspect


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P"06A"; LE$024

Primary lesions are the first toappear and are due to thedisease or abnormal state


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A* &A$.LE

flat, nonpalpable circumscribed area of color changein the s%in! 6acules are < # cm in si5e!

6acules may be the result of

+Ainflammatory 'ascular dilation-hyperemia+9bleeding-hemorhagia-purpura

+3change of s%in pigmentation


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A*)* Hypereia /0as+"lar dilatation1

+Latin hyper: = o'er> :emia = related to blood is atemporary s%in redness due to increased blood flow in aparticular s%in, or mucosal area! The lesion blanch uponpressure +diascopy!

! "oseola +@ cm-nail plate#! Erytematous + cm

&! Telengictasis : dilated

superficial blood 'essels,especially of the upperreticular dermal plexus!


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A purpura (Latin purpura = purple) is a small (3mm– 1 cm) purplish bruise/ violaceous color due toextravasations of blood into the tissue. t does notblanch on appl!in" the pressure.1.#etechia $ (Latin petecchia (plural = petechiae) =spot on s%in) is a small (& 3 mm) red or purple bruise'.ibises3.cchimoses (lar"e* + 3 mm)

cchimoses* purpurae* and petechiae are caused b!trauma* or disorders of the blood or vessels

A*2* Heorha#ia3p"rp"ra


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A*4* $han#e of skin pi#entation

! Byperpigmentation increase of pigmentation

o! 6elasma gra'idarum o! Efelides-fri%el o! Drugs : $ulfonamide, Cina o! Addisons disease

o! 6ongolian spot

Biperpigmentation


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#! Bypopigmentation decrease of pigmentationo! Pithyriasis 'ersicolor

o! Leucoderma

&! Depigmentasi no pigmento! 7itiligo

Bipopigmentation

http://www.pediatrics.wisc.edu/derm/tuta/03.html


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•

$mall solid ele'ation of s%in generally < mm in diameter!• Papules may be flattopped, as in lichen planus> or dome shaped, asin xanthomas> or spicular, if related to hair follicles

• Papules may result from :

+A dermal metabolic deposits

+9 locali5ed dermal cellular infiltrates

+3 locali5ed hyperplasia of dermal or epidermal cellularelements

(* PAP.LE


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Two firm domeshaped papules dermalmelanocytic ne'i

6ultiple welldefined and coalescing papules lichen planus!

$ PLA5.E


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palpable, plateauli%e ele'ation of s%in, usually more than #cm in diameter and rarely more than mm in height! 2ftenformed by a con'ergence of papules, as in psoriasis!

$* PLA5.E


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Pla/ues occupy a relati'ely largesurface area in comparison with itsheight abo'e the s%in!

elldefined, reddish,scaling pla/ues

http://dermnetnz.org/common/image.php?path=/scaly/img/ps3.jpg


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7esicles are raised lesions less than cm! in diameter

that are filled with clear fluid! 7esicle walls can be sothin that the contained serum, lymph, blood, orextracellular fluid is easily seen! 1luid can beaccumulated within or below the epidermis!

!* 6ESI$LE

http://www.dermnet.com/image.cfm?passedArrayIndex=15&moduleID=21&moduleGroupID=307


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E (.LA /(LISTER1


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9ula +Lat! bulla = bubble is a 'esicle that exceeds cm in si5e

circumscribed, ele'ated lesion that is cm in diameter, containingserous +clear fluid! A 'esicle-bulla is the technical term forblisters!

E* (.LA /(LISTER1

F P.ST.LE


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superficial, ele'ated lesion that contains pus +pus ina blister! Pustules may 'ary in si5e and shape! The

color may appear white, yellow, or greenishyellowdepending on the color of the pus! Pus is composedof leu%ocytes with or without cellular debris! 0tmay also contain bacteria or may be sterile!

F* P.ST.LE


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A pustule is basically a papule

containing pus

$uperficial, subcornealpustules pustular psoriasis


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palpa-le7 solid7 ro"nd7 or ellipsoidal lesion* 0ts depth of in'ol'ement

and-or palpability differentiate it from a papule rather than itsdiameter +although nodules are usually larger than papules: mmdiameter! 4odules can in'ol'e any layer of the s%in and can beedematous or solid! 9ased on the anatomical component+s in'ol'ed,there are fi'e types of nodules: epidermal, epidermaldermal, dermal,

dermalsubdermal, and subcutaneous!Telangiectasia can be seen

G* NO!.LE

H $YST


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An epithelial lined ca'ity containing

li/uid or semisolid material +fluid, cells,and cell products! A spherical or o'alpapule or nodule may be a cyst if, whenpalpated, is resilient +feels li%e aneyeball!

! 6ost common are +A epidermalcysts, lined by s/uamous epithelium andproduce %eratinous material! +9 Pilarcysts, lined by multilayered epitheliumwhich does not mature through the

granular layer!

#! 9luish, resilient cyst filled withmucous material adnexal tumor+cystic hidradenoma!

H* $YST


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Transitory, compressible papule

or pla/ue of dermal edema!

The papule or pla/ue is usuallyrounded or flattoped, ande'anescent, disappearing within

hours! The borders of a whealare sharp, but not stable andcan mo'e from in'ol'ed toad(acent unin'ol'ed areas o'er

hours!

A wheal may be large coalescingpla/ues as in this allergicreaction!

I* 8HEAL OR .RTI$A


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An er"ption of 9heals is tered "rti+aria and"s"ally it+hes


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, -omedo

acne, elen"iectasion, urro0 scabies

* SPE$IAL LESION


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$E324DA"; LE$024

"esult from the naturale'olution of primary lesions

E


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$cale accumulation or abnormal shedding of horny

layer %eratin +stratum corneum in perceptiblefla%es! $cales usually indicate inflammatory changeand thic%ening of the epidermis! The may be fine,as in pityriasis> white and sil'ery, as in psoriasis> orlarge and fishli%e, as in ichtyosis

A* S$ALE

+A Para%eratotic scale +withretained nuclei can be seen inpsoriasiform epidermal

hyperplasia

+9 Actinic %eratosis is adensely adherent scale withgritty feel due to a locali5edincrease in stratum corneum


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Typical psoriasis scaling

$cales may build up to form an asbestosli%e layerco'ering the underlying lesion!

( L$ER


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circumscribed area of s%in lossextending through the epidermisand at least part of the dermis+papillary!

! 9asically, it.s a Fhole in thes%inF! 8lcers usually result fromthe impairment of 'ascular andnutrient supply to the s%in!

#! Gigantic ulcer, red granulatingbase with punched out borders!

(* .L$ER

$ $R. T


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• Dried serum, blood, or pus

on the surface of s%in!6ay be thin, delicate, andfriable or thic% andadherent!

• 3rusts are yellow, if fromserum> green or yellowgreenif from pus> or brown ordar% red if formed fromblood! 3haracteristic of

pyogenic infections!• 3rusts that occur ashoneycoloured, delicate,glistening particulates aretypical of 0mpetigo!

$* $R.ST

! EROSION < E%$ORATION


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Erosion: oist7 +ir+"s+ri-ed7

sli#htly depressed areas of skind"e to loss of all or part of theepideris

)* Often res"lts fro er"ptionsof 0esi+les and -"llae* Seen ininfe+tion fro herpes 0ir"ses andin pephi#"s*

2* To;i+ epideral ne+rosis+a"ses erosion*

!* EROSION < E%$ORATION


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E;+oriation: linear orpunctate superficial

exca'ations of epidermiscaused by scratching,rubbing, or pic%ing!

E LI$HENIFI$ATION


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3hronic thic%ening of the s%in along with increased s%inmar%ings! "esults from scratching or rubbing!

E* LI$HENIFI$ATION

F ATROPHY


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There is loss of normal s%in texture

Paperthin, wrin%led s%in with easily 'isible'essels! "esults from loss of epidermis,dermis or both! $een in aged, some burns,and longterm use of highly potent topicalcorticosteroids!

+A Dermal atrophy manifests as adepression in the s%in

+9 Epidermal atrophy manifests as thinalmost transparent s%in> may not retain

normal s%in lines!

F* ATROPHY

G S$AR


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"eplacement of normal

tissue by fibrous connecti'etissue at eh site of in(ury tothe dermis! $cars may behypertrophic, atrophic,sclerotic or hard due tocollagen proliferation!"eflects pattern of healingin the affected area!

! +A Bypotrophic or +9atrophic scar!

#! Bypertrophic scar!

G* S$AR

H FISS.RE /RHAGA!E1


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A fissure is linear clea'age of s%in which extendsinto the dermis!

H* FISS.RE /RHAGA!E1


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A""A4GE6E4T A4D

32410G8"AT024


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Linear lesions occur in a lineor bandli%e configuration!This descripti'e term may

apply to a wide 'ariety ofdisorders! 2ne should becertain that the lesions arenot following a dermatome

)* LINEAR LESION


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2* 'OE(NER PHENO&ENON

The Coebner phenomenon,also called the isomorphicresponse, refers to theappearance of lesions alonga site of in(ury! This

phenomenon is seen in a'ariety of conditions> forexample, lichen planus,warts, molluscum

contagiosum, psoriasis,lichen nitidus, and thesystemic form of (u'enilerheumatoid arthritis!


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4* G.TTATE

Guttate lesions loo% asthough someone too% adropper and dropped thislesion on the s%in! Guttatelesions are characteristicof one form of psoriasis,

though that is not the onlyexample!

= ANN.LAR


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Annular lesions are seen in a ring shape! Tinea corporis,

erythema migrans +the lesion associated with lymedisease, and granuloma annulare are three commonexamples!

=* ANN.LAR


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>* $ONFL.ENT

3onfluent lesions tend to run together


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D0$T"098T024 21 $C04

LE$024


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Documents

1. BCS LCD Efloresensi dr. PS.ppt