Approach to a Dermatologic August 27, 2010

Physical Examination of the Skin The diagnosis and treatment of dermatologic disease rests

on the physician’s ability to recognize the basic and sequential lesions of the skin

Skin lesions: visible and accessibleo Advantage: since it is accessible, an intervention such as a

biopsy can be performed easilyo Disadvantage: There are thousands of skin diseases that

for some (especially first-timers) would look the same (thus, one must be keen enough to distinguish)

Physicians: must learn to “read” skin for clues to underlying systemic disease

** sometimes a history is no longer needed in order to make a diagnosis

Detailed Examination of the Integumentary System Skin Hair Nails Mucous membranes

Major Characteristics of Skin Lesions1. Color a factor of 4 pigments

a. Melanin (brownish hue)b. Oxyhemoglobin (reddish/erythematous hue)c. Deoxyhemoglobin (bluish hue)d. Carotene (yellowish hue)

2. Consistency and feel of lesion(via palpation) Soft, doughy, firm, hard, “infiltrated”, dry, moist, mobile,

tender

Abnormalities in Skin ColorBrownish Discoloration Café au lait spots (increased melanin production)o Neurofibrimatosis/von Recklinghausen’s Disease, von

Hippel – Lindau disease, McCune-Albright syndrome Addison’s disease (deposition of melanin in the mucous

membrane) Can be found in normal people

Bronze, Dark or Grayish Black Discoloration Hemochromatosiso Iron deposition in pancreas e.g., DM

Yellow Skin Discoloration /Jaundice Inc serum bilirubino RBC hemolysis yellowish skin and sclera (most

prominent discoloration) Anemiao Yellow tinge – sallow appearanceo Best seen in areas where stratum corneum is thinnest

(nails, lips, mucous membrane & palpebral conjunctiva)

Hypopigmentation - Vitiligo Acquired /autoimmune loss of melanin pigment Related to other autoimmune diseases such as Hashimoto’s

Thyroiditis, hyperthyroidism, DM, pernicious anemia Chalk-white discoloration

Erythema (Redness) Increased cutaneous flow Most commonly a component of inflammationo E.g., Drug eruption, viral exanthema (with fever, malaise,

joint pains, lymphadenopathy)o To distinguish – obtain drug intake history (2-4 weeks)

Drugs that may cause Discoloration Clofazimin (Leprosy drug)o Dark browno Main lesion discoloration

Quinacrine (antimalarial)o Yellow

Amiodarone (antihypertensive, antiarrhythmic) o Bluish

Minocycline (for severe acne)o Bluish

Turgor Rapid assessment of tissue hydration

Lift a fold of skin and note ease with which it is moved (mobility) & speed with which it returns to place (turgor)

Faster return means better hydration for the patient Increase in turgor if it remains elevated

Hair Facial, axillary & pubic hairs dependent on presence of sex

hormones, thus, affected by sex & age of patient If with excessive hair, suggestive of endocrine disease Alopecia areata - balding

Nails May provide a clue to certain systemic diseaseo Psoriasis vulgaris (oil spots, onycholysis, loosening of nail,

crumbling of nail, little pits on nails) Renal disease – Half & half nails (proximal white & distal

pink/brown) Hemochromatosiso Spoon nails (koilonychia)

Due to faulty iron metabolism Pulmonary, cardiac, hepatic & GIT diseaseo Clubbing (more common in cardiac diseases)

Four Cardinal FeaturesType of Lesion Primary or Secondary E.g., macule, papule, nodule, vesicle

Shape and Arrangement of Lesions Provide Clues to the DiagnosisLinear Phytodermatitis- plant dermatitis Allergic reaction to plant particles usually seen in exposed

areas of gardeners/housewivesIris/Target “bull’s eye” or iris lesions Erythema on periphery and central portion (papule or vesicle)

of discoloration – violet or purple color Steven Johnson’s Syndrome Pathognomonic of erythema multiforme

Herpetiform Herpes simplex virus

Annular / Ring like Fungal infections Tinea capitis/ tinea corporis

Arciform – arc-likePolycyclic – different shapes (seen in granuloma annulare - HIV) Grouped lesions – xanthomas (cholesterol deposits that can be yellowish or reddish)RoundOvalVesicles in a band on dermatome/ zosteriform Herpes zoster Only one side of body 50-70%- found in trunk Multiple coalescing vesicles; erythematous lesion

Umbilicated – looks like an umbilicus (presence of indentation in the middle part

Distribution Extent of involvement – circumscribed, regional, generalized,

universal (*generalized – entire body) What percent of the body surface is involved? (entire palm is

roughly 1%) Pattern – symmetry, exposed areas, sites of pressure,

intertriginous areaso * pressure – urticariao * intertriginous – fungal/candidal infections axillary,

intramammary, inguinal areas Characteristic locationo Flexural – e.g., childhood atopic dermatitiso Extensorso Intertriginous areaso Glabrous – areas without hairo Palms and soles (e.g., scabies)o Dermatomalo Trunkso Lower extremitieso Exposed areas

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Basic/Primary Skin Lesions- Most of the time, patient does not have basic lesion anymore due to late consultation

Macule Circumscribed, flat lesiono 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 papuleo Depth (not diameter) distinguishes it from papuleo Hard, soft, movable, fixed, etc

Neurofibromatosis nevi, warts, lichen planus, insect bites, seborrheic and actinic

Wheal Hives/uticariao Evanescent flat/ rounded papule or plaque, pink

(evanescent meaning can travel from one location to another within 24 hours)

o Epidermis- unaffectedo Borders – unstableo Allergic responseo “dermographism” – when there is scratching an elevated

lesion will occur at the site due to histamine’s effect on the skin

o Warmo 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 Puso Leukocytes, cellular debris

Furuncle (deep necrotizing folliculitis)o Deep necrotizing folliculitis

Carbuncleo Coalescing furuncles

*folliculitis furuncle carbuncle * increase incidence of folliculitis during the summer heat aggravates Staph infections

Secondary LesionsCrust Results when serum, blood or purulent exudates dries on the

skin surface Characteristic of injury & pyogenic infectionso Yellow – dried serumo Green/ yellow green – purulent exudateso Brown/ dark red- bloodo 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 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 thigho Pityriasiform – brannyo Psoriasiform – micaceouso Icthyosiform – fish scaleso Keratotic – horny masseso Follicular – keratotic plugs

Clinical TestsDimple Sign Dermatofibroma Apply pressure feels like a button/depression [(+) test]

Nikolsky’s 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

Darier’s 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..)

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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

inspectiono Use magnifying glass, oblique lighting and wood’s lamp

Palpation, diascopy, scratching of lesionso 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 Biopsyo Punch biopsy – disposableo 2-10mm diametero Punch thru layers, making sure to include all up to fat areao Apply local anesthetic

Gram staino Crusts, scales, exudates

Potassium hydroxide examinationo For yeast and fungio 10% KOH causes separation of epidermal cells, allows

visualization of hyphae/sporeso Tinea versicolor – spaghetti and meatballs appearance

Tzanck smearo Vesicular and bullous lesionso Direct smear of the floor of lesion to look for giant

multinucleated cells Wood’s light examinationo Filtered UV lighto Urine-porphyriao Hair and skin – changes in pigmentation, fluorescence

Patch testso Document sensitivity to a substance or antigens

Diascopyo Differentiates vasculitis(blanching absent) from erythema

(blanching present)

References:Lecture and Notes from Dr. MedelUltimate Mafia Trans

Trans by: Relloras, Revelo, Reyes

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