Approach to a Dermatologic

Patient
Dr. Ruth B. Medel, MD, FPDS

August 27, 2010

Physical Examination of the Skin

The diagnosis and treatment of dermatologic disease rests
on the physicians ability to recognize the basic and
sequential lesions of the skin
Skin lesions: visible and accessible
o Advantage: since it is accessible, an intervention such as a
biopsy can be performed easily
o 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 Lesions
1. 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 Color
Brownish Discoloration
Caf au lait spots (increased melanin production)
o Neurofibrimatosis/von Recklinghausens Disease, von
Hippel Lindau disease, McCune-Albright syndrome
Addisons disease (deposition of melanin in the mucous
membrane)
Can be found in normal people
Bronze, Dark or Grayish Black Discoloration
Hemochromatosis
o Iron deposition in pancreas e.g., DM
Yellow Skin Discoloration /Jaundice
Inc serum bilirubin
o RBC hemolysis yellowish skin and sclera (most
prominent discoloration)
Anemia
o Yellow tinge sallow appearance
o 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 Hashimotos
Thyroiditis, hyperthyroidism, DM, pernicious anemia
Chalk-white discoloration
Erythema (Redness)
Increased cutaneous flow
Most commonly a component of inflammation
o 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 brown
o 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 disease
o 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)
Hemochromatosis
o Spoon nails (koilonychia)
Due to faulty iron metabolism
Pulmonary, cardiac, hepatic & GIT disease
o Clubbing (more common in cardiac diseases)
Four Cardinal Features
Type of Lesion
Primary or Secondary
E.g., macule, papule, nodule, vesicle
Shape and Arrangement of Lesions Provide Clues to the
Diagnosis
Linear
Phytodermatitis- plant dermatitis
Allergic reaction to plant particles usually seen in exposed
areas of gardeners/housewives
Iris/Target
bulls eye or iris lesions
Erythema on periphery and central portion (papule or vesicle)
of discoloration violet or purple color
Steven Johnsons Syndrome
Pathognomonic of erythema multiforme
Herpetiform
Herpes simplex virus
Annular / Ring like
Fungal infections
Tinea capitis/ tinea corporis
Arciform arc-like
Polycyclic different shapes (seen in granuloma annulare - HIV)
Grouped lesions xanthomas (cholesterol deposits that can be
yellowish or reddish)
Round
Oval
Vesicles 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 areas
o * pressure urticaria
o * intertriginous fungal/candidal infections axillary,
intramammary, inguinal areas

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 Characteristic location
o Flexural e.g., childhood atopic dermatitis
o Extensors
o Intertriginous areas
o Glabrous areas without hair
o Palms and soles (e.g., scabies)
o Dermatomal
o Trunks
o Lower extremities
o 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 Borders unstable
o Allergic response
o dermographism when there is scratching an elevated
lesion will occur at the site due to histamines effect on the
skin
o Warm
o 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
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

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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

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
o 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)

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

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
o Crusts, scales, exudates
Potassium hydroxide examination

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