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Dermatological History and Examination

age, sexChief complaint : + duration

itchingburningpain

History of present illness

When and how started?

Mild, moderate or severe?Aggravating or reliving factors?Any other symptomsReview of systemsPast medical history

Drug history

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OccupationHobbiesTravelFamily history

Examination:

3 corners to make useful skin exam 1. Morphology (shape of the lesion)2. Configuration (arrangement of lesions)3. Distribution (Which body site)• Morphology:- 1º skin lesions : unmodified lesions - 2º skin lesion: modified by scratching or

infection

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Primary Lesions Secondary lesions

Macule CrustPapule ErosionPlaque ScaleNodule UlcerationCyst ExcoriationWheal ScarVesicle AtrophyBulla FissurePurpura NecrosisBurrow LichenificationTelangectasia

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Primary skin lesions

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Macule & patch

• A macule is a circumscribed flat alteration in the colour of the skin which is less than 1 cm in diameter.

• Various colors depending on the cause

• A patch is a flat lesion greater than 1 cm in diameter (i.e. a large macule).

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Papule

• A papule is a circumscribed palpable elevation of the skin less than 1 cm in diameter

• Dermal(drug eruption, lipid deposits), epidermal (warts, molluscum), or both (lichen planus)

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Nodule

Palpable solid deep lesion (depth> diameter)

- Epidermal

- Dermal

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Plaque

• A slightly raised lesion greater than 1 cm in diameter

• Papules confluence (psoriasis)

• Patch thickening (mycosis fungoides)

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Vesicle

• A raised lesion less than 0.5 cm in diameter containing clear fluid

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Bulla

• A vesicle that is greater than 0.5 cm in diameter is known as a bulla.

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Pustule

• A pustule is a raised lesion less than 0.5 cm in diameter containing yellow fluid, which may be sterile as in acne or pustular psoriasis, or infected.

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Wheal

• A wheal is a transient, itchy, pink or red swelling of the skin, often with central pallor.

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Cyst:

palpable soft sac containing fluid.

- Epidermal

- Dermal

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Telangiectasia

• Dilatation of capillaries gives rise to this skin condition.

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Secondary skin lesions

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Crust

• A crust is a dried exudate, which may have been serous, purulent or haemorrhagic.

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Excoriation

• A haemorrhagic excavation of the skin resulting from scratching.

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Lichenification

• Thickening of the skin with exaggeration of the skin creases.

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Scar

• The final stage of healing of a destructive process (disease or injury) that has involved the deeper dermis results in a white, smooth, firm, shiny lesion.

• Atrophic, or hypertrophic

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Scale

• A scale is a flat plate (lamella) or flake of stratum corneum.

• The epidermis is replaced in cycles• Fine (eczema) / thick (psoriasis) • No scaling in dermal pathologies

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Poikiloderma

• This refers to an appearance of pigmentation, atrophy and telangiectasia

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Necrosis

• Death, or necrosis, of skin tissue is usually black in colour.

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Erosion

• A partial break in the epidermis is known as an erosion

• It heals without scarring unless secondary infection occurs.

• Commonly following a blister

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Ulcer

• An ulcer is a full-thickness loss of the epidermis

• Heals with scarring

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FISSURE

a linear cleavages or cracks in the skin.

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Atrophy

• Thinning and transparency of the skin

• Caused by diminution of the epidermis, the dermis, or both

• Wrinkling and translucency

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Primary Lesions

•Macule: Flat circumscribed area of change in skin color•Papule: small circumscribed elevation of the skin•Nodule:Solid, circumscribed elevation of the skin whose greater part is beneath skin surface (felt more than seen)•Plaque: flat topped palpable lesion (gathering of papules)•Vesicle: collection of clear fluid (<5mm in diameter)•Bulla: like vesicle, but > 5 mm•Pustule: Collection of Pus

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Primary Lesions

* Wheal: Transient, slightly raised lesion with pale center and pink margin.Seen in urticaria.

* Purpura:Visible collection of blood under the skin e.g. Vasculitis

* Telangectasia: Dilated capillaries visible on skin surface

* Burrow: Tunnel in the skin (e.g. Scabies)

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Secondary lesions•Crust: Dried serum (or exudate)•Scale:Thickened, loose, readily detached fragment of cornified layer•Excoration: Shallow linear abrasion caused by scratching.• Erosion:Loss of epidermis (heals without scarring)•Ulcer: loss of epidermis and dermis (heals with scarring)• Fissure : linear crack in the skin•Scar: Permanent lesion due to abnormal formation of connective tissue following injury.

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Secondary lesions

Atrophy: A-Superficial: thining of skin with visible blood vessels

B-Deep : depression of skin surface

Lichenification: thickened skin with

accentuated skin markings

Sclerosis: induration of skin

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Distribution

Predilection for specific body sites*Psoriasis: Extensors(elbows and knees)

Scalp*Acne:Face

Upper chest, Upper back*Photosensitive eruption: Mainly face, forearms & V-Chest (with sparing of photoprotected areas e.g. upper eyelids, retro-auricular an sub- mental)

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Colour in Dermatology

Red:Vascular lesions e.g. port wine stain

also, inflammatory disorders like psoriasisBlue: Blue nevus

Mongolian spotYellow: XanthomaWhite: VitiligoBlack: Melanocytic nevus & melanomaPurple or (Violaceous) : Lichen planus

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Some important signs in Dermatology

*Auspitz sign: When you remove a scale from psoriasis lesion tiny bleeding points (due to suprapapillary thinning).

Nikolsky sign: When you rub normal skin beside blister induction of new blister .Seen in pemphigus vulgaris and toxic epidermal necrolysis(TEN).

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Nikolsky sign

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Dermatographism: When you stroke the normal skin edema and erythema (you can write on skin!) .Seen in physical urticaria

Kobener Phenomenon: Induction of new skin lesions on previously normal appearing skin by truma e.g. in psoriasis, wart, lichen planus

Button-hole sign: In neurofirbroma, if you try to push it it goes inside the skin

Kobener Phenomenon

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Dermatographism

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Additional skin examination:~Wood’s Lamp: Produces long wave ultraviolet light(UVA). e.g. Vitiligo milky whiteTinea Versicolor goldenTinea Capitis (caused by microsporum) yellow greenErytherasma coral red

~Diascopy:you press with a glass slide .If there is red lesion and the redness dose not go away by this pressure this means extravasated blood i.e.purpura

~Dermatoscopy: Helpful to differentiate benign from malignant pigmented lesions.

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Diascopy

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Investigations:*KOH and fungal culture•Scrap skin scales put over glass slide•Add KOH 10% -- warm gently•See under microscope•You may see hyphae and/ or spores

*Gram stain and bacterial culture

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Investigations:Tzank smear: Scrap base of vesicle smear it on microscopic slide add fixative add Giemsa stain.Examine under microscope for 1.Detached epidermal cells (acantholytic cells) in pemphigus vulgaris2.Multinucleated giant cells in herpes simplex, zoster or varicella

Viral culture

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Skin biopsy : Under local anasthesia, different types: Punch

ShaveExcisionalIncisional

Immunofloursence : important in immunobullous disorder

1. Direct : use pt’s skin2. Indirect: use pt’s Serum

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Thank you