Diagnosis of

Skin Diseases

History and Physical

Examination
90% of skin diseases can be properly diagnosed with
meticulous history and proper physical examination.
In the history the chief complaint, onset, progression,
associated symptoms, drug history, past medical
history, personal history, family history, race, system
review are all important.
The prinicipal steps in physical examination are
palpation and inspection.

Skin Lesions
Classified as PRIMARY& SECONDARY SKIN
LESIONS.

Primary Skin Lesions

Macule
Patch
Papule
Nodule
Tumor
Plaque
Vesicle
Pustule
Bullae
Wheal
Telangiectasia
Abscess
Petechiae, purpura & ecchymosis

Macule
A flat, colored
lesion, <1cm in
diameter,
not
raised above the
surface of
surrounding skin
Freckle prototype
of pigmented
macule

Macule

patch
A large(>2cm
diametr)flat lesion
with a color
different from
surrounding skin
Differs from macule
only in size

Papule
A small, solid
lesion,
<0.5 cm
in diameter, raised
above the surface
of surrounding skin
& hence palpable
Eg: white head in
acne

Papule

Nodule
A large ( >1 cm ),
firm lesion raised
above the surface
of surrounding skin.
Differs from papule
only in size.
Diameter=thicknes
s

Tumor
A solid,raised
growth >2cm in
diameter

Plaque
A large >1cm, flat
topped/plateau like
raised lesion, edges
may either be
distinct ( in
psoriasis ) or
gradually blend
with surrounding
skin ( in
eczematous
dermatitis)
Diameter greater

Vesicle
are small papule,
fluid filled lesion,
<1cm in diameter,
raised above the
plane of
surrounding skin.
Fluid is often visible
and the lesion are
translucent
Vesicles in Allergic
Contact Dermatitis

Pustule
A vesicle filled with
leukocytes & pus
<1cm
The presence of
pustule does not
necessarily signify
the the existance of
infection

Abscess
A localised
collection of pus in
a cavity, more than
1 cm in diameter

bulla
A fluid filled ,
raised, often a
translucent lesion
>1cm in diameter
and it is the larger
form of vesicles.

Wheal
A raised,
erythematous,
edematous,
papule / plaque,
usually
representing shortlived vasodilatation
and
vasopermeability
Eg: utricaria

telangiectasia
A dilated superficial
blood vessel like
JVP.

Petechiae, purpura &

ecchymosis
Petechiae pinhead-sized macules of extra
vascular blood in the dermis.
Petechiae are flat.
The larger ones are referred to as purpura
If bleeding involves deeper structures then it is
called ecchymosis

Burrow
A linear or cuvillinear papule, caused by
burrowing scabies mite

Comedones
A plug of keratin and sebum wedged in dilated
pilosebaceous orifice.

Secondary Skin Lesions

Scale
Crust
Excoriation
Erosion
Fissure
Sinus
Scar
Atrophy
Striae
Lichenification

Scale
A flake arising from
stratum corneum
d/t excessive
accumulation.
Eg: psoriasis

Crust
Dried exudate of
body fluids (blood /
serous fluid)
Which might be
either yellow
( serous crust )
red (hemorrhagic
crust )

Ulcer
An area of skin
from which the
whole of epidermis
& atleast the upper
part of dermis has
been lost

Excoriation
Linear, angular
erosions that may
be covered by crust
and are caused by
scratching.

Erosion
Area of skin
denuded(removed)
by complete or
partial loss of
epidermis.
No associated loss
of dermis

Fissure
A slit- shaped deep
ulcer
Eg: irritant
dermatitis of hands

Sinus
A cavity or channel
that permits the
escape of pus or
fluid

Scar
A change in the
skin secondary to
trauma or
inflammation
Sites may be
erythematous,
hypopigmented or
hyperpigmented
depending upon
their age
/character.

Scar

Atrophy
An acquired loss of
substance .
In skin, this may
appear as a depression
with intact epidermis
( loss of dermal /sub
dermal tissues )
Or appear as sites of
shiny, delicate,
wrinkled lesions
( epidermal atrophy )

Striae
A streak like,
linear , atrophic,
pink, purple or
white lesion d/t
changes in
connective tissue
Eg: cushings
syndrome,
pregnancy induced

Lichenification
A distinctive
thickening of skin
that is
characterized by
accenuated skinfold markings.

Primary Skin Lesions

Macule: flat area of altered colour or texture (less than 0.5 cm)
Patch: large macule (more than 2 cm in diameter)
Papule: elevated solid lesion (less than 0.5 cm)
Nodule: elevated solid lesion (more than 0.5 cm, diameter
=thickness)

Plaque: elevated area of skin of more than 2 cm in

diameter(diameter> the thickness).

Vesicle: fluid filled papule (less than 0.5 cm)

Bulla: larger blister (more than 0.5 cm)

TUMOR- larger bullae or nodule(more than 2cm)

Pustule: collection of free pus

Abscess: localized collection of pus in a cavity (more than 1 cm)
Petechia, Ecchymosis, Purpura
Telangiectasia

Secondary Skin Lesions

Scale: flake from the horny layer

Crust: dried serum, exudates or tissue fluid
Ulcer: whole of the epidermis and part of dermis lost
Excoriation: linear erosion or ulcer produced by
scratching
Erosion: partial loss of the epidermis
Fissure: slit in the skin
Sinus: channel that permits escape of pus or fluid
Scar: result of healing, normal structure replaced by
fibrous tissue
Atrophy: thinning of skin.

Arrangement of Skin Lesions

Discrete/separate
Grouped/coalese
Linear
Arcuate
Circinate
Gyrate

Distribution of Skin Lesions

Symmetry, asymmetry
Flexural, extensor
Exposed, Covered
Photo
Sebaceous
Dermatomal/Segmental
Acral, Central
Palms and soles

Special Techniques
1.
2.
3.
4.
5.
6.
7.
8.

Effect of rubbing
Magnification
Diascopy
Woods Light Examination
Percutaneous Testing
Mite Examination
KOH Examination
Tzank Smear

Principles of Treatment
Drugs for skin diseases could be given topicaly,
oraly, parentraly or intralesionaly.
Topical therapy is the milestone
Considering the active ingradient coupled with the
vehicle is important.
Topical preparations are classified based on the
vehicle.

 Creams
Ointments
Lotions
Shampoos
Pastes
Gels

Topical Steroids
The most commonly used topical preparations
Improper use has led to significant side effects
Classified based on their potency in to four

Class
Class
Class
Class

I
II
III
IV

Principles of using topical

steroids
Dont use for uncertain diagnosis and cosmetic
reason
First treat concomittent infection
Use the mildest steroid possible
Dont apply potent steroids to the baby skin, face
and intertreginous areas
Dont apply potent steroids more than two weeks.

Side Effects of Steroids

Local

Balnching
Atrophy
Acne form eruptions
Infections
Glaucoma
Cataract

Systemic side effects.