APPROACH to the PATIENT with a

SKIN DISORDER
 APPROACH to the PATIENT:
• 4 Basic features of any cutaneous lesion that
must be noted and considered:

– 1) the distribution of the eruption

– 2) the types of primary and secondary lesions

– 3) the shape of individual lesions

– 4) the arrangement of the lesions

 APPROACH to the PATIENT:
• A complete history should be obtained to emphasize the
following features:

– 1. Evolution of lesions:
• A. Site of onset
• B. Manner in which the eruption progressed or spread
• C. Duration
• D. Periods of resolution or improvement in chronic eruptions

– 2. Symptoms associated with the eruption

• A. Itching, burning, pain, numbness
• B. What, if anything, has relieved symptoms
• C. Time of day when symptoms are most severe
 APPROACH to the PATIENT:
– 3. Current or recent medications (prescribed as well as over-the counter)

– 4. Associated systemic symptoms (e.g., malaise, fever, arthralgias)

– 5. Ongoing or previous illnesses

– 6. History of allergies

– 7. Presence of photosensitivity

– 8. Review of systems

– 9. Family history

– 10. Social, sexual or travel history

 PRIMARY SKIN LESIONS:
• MACULE:
– A flat, colored lesion < 2cm in diameter, not raised above the surface of the
surrounding skin (e.g., freckle)

• PATCH:
– A large (> 2cm), flat lesion with a color different from the surrounding skin

• PAPULE:
– A small, solid lesion< 0.5 cm in diameter, raised above the surface of the
surrounding skin and hence palpable (e.g., whitehead)

• NODULE:
– A larger (0.5-5.0 cm), firm lesion raised above the surface of the surrounding
skin (e.g., dermal nevus)
 PRIMARY SKIN LESIONS:
• TUMOR:
– A solid, raised growth > 5cm in diameter

• PLAQUE:
– A large (> 1cm), flat-topped raised lesion
– Example: psoriasis

• VESICLE:
– A small, fluid-filled lesion, < 0.5 cm in diameter, raised above the plane
of surrounding skin

• BULLA:
– A fluid-filled, raised , often translucent lesion >0.5cm in diameter
 PRIMARY SKIN LESIONS:
• PUSTULE:
– A vesicle filled with leukocytes

• CYST:
– A soft, raised, encapsulated lesion filled with semi-solid or liquid
contents

• WHEAL:
– A raised, erythematous papule or plaque, usually representing short-
lived dermal edema

• TELANGIECTASIA:
– Dilated, superficial blood vessels
COMMON DERMATOLOGIC TERMS:
• LICHENIFICATION:
– A distinctive thickening of the skin that is characterized by
accentuated skin fold markings and that feels thick on palpation

• SCALE:
– Excessive accumulation of stratum corneum

• CRUST:
– Dried exudate of body fluids that may be either yellow (serous
exudate) or red (hemorrhagic exudate)

• EROSION:
– Loss of epidermis without an associated loss of dermis
 COMMON DERMATOLOGIC
TERMS:
• ULCER:
– Loss of epidermis and at least a portion of the underlying dermis

• EXCORIATIONS:
– Linear, angular erosions that may be covered by crust and are caused
by scratching

• ATROPHY:
– An acquired loss of substance in the skin
– Appears as:
• A depression with intact epidermis (i.e., loss of dermal or subcutaneous tissue)
• Sites of shiny, delicate, wrinkled lesions (i.e., epidermal atrophy)
 COMMON DERMATOLOGIC TERMS:
• SCAR: contact dermatitis)
– A change in the skin secondary to • Xerosis and aged skin
trauma or inflammation • Systemic conditions:
– Sites may be erythematous, – Chronic renal disease
hypopigmented or hypertrophic – Cholestasis
depending on the age or character
– Pregnancy
– Sites on hair-bearing areas may be
characterized by destruction of – Malignancy
hair follicles – Thyroid disease
• PRURITUS: – Polycythemia vera
– A sensation that elicits the desire – Parasitosis
to scratch
– The predominant symptom of:
• Inflammatory skin diseases
(e.g., atopic dermatitis, allergic
COMMON DERMATOLOGIC TERMS:
• ALOPECIA:
– Partial or complete hair loss

• HERPETIFORM:
– Refers to lesions n a grouped configuration

• LICHENOID ERUPTION:
– Violaceous to purple, polygonal lesions that resemble those
seen in lichen planus

• MILIA:
– Small, firm, white papules filled with keratiin
COMMON DERMATOLOGIC TERMS:
• MORBILIFORM RASH:
– Generalized, small erythematous macules and/or papules that
resemble lesions seen in measles

• NUMMULAR:
– Coin-shaped lesion

• POIKILODERMA:
– Skin that displays variegated pigmentation, atrophy and telangiectases

• POLYCYCLIC LESIONS:
– A configuration of skin lesions formed from coalescing rings or
incomplete rings
PRIMARY SKIN LESIONS
PRIMARY SKIN LESIONS
PRIMARY SKIN LESIONS
PRIMARY SKIN LESIONS
PRIMARY SKIN LESIONS
PRIMARY SKIN LESIONS
PRIMARY SKIN LESIONS
PRIMARY SKIN LESIONS
PRIMARY SKIN LESIONS
PRIMARY SKIN LESIONS
PRIMARY SKIN LESIONS
SECONDARY SKIN LESIONS
SECONDARY SKIN LESIONS
SECONDARY SKIN LESIONS
SECONDARY SKIN LESIONS
SKIN LESIONS: PATTERNS AND
SHAPES
DISTRIBUTION of COMMON
DERMATOLOGIC LESIONS:
DISTRIBUTION of COMMON
DERMATOLOGIC LESIONS:
DISTRIBUTION of COMMON
DERMATOLOGIC LESIONS:
DISTRIBUTION of COMMON
DERMATOLOGIC LESIONS:
 DIAGNOSTIC TECHNIQUES:
• SKIN BIOPSY:
– A small area of skin is anesthesized with 1% lidocaine with or without
epinephrine
– The skin lesion in question can be excised with a scalpel or removed by
punch biopsy
• POTASSIUM HYDROXIDE (KOH) PREPARATION:
– Performed on scaling skin lesions where a fungal etiology is a possibility
– The edge of the lesion is scraped gently with a scalpel blade and placed on
a glass microscope slide treated with 1-2 drops of 10 to 20% KOH
– KOH dissolves keratin and allows visualization of fungal elements:
• Hyphae (dermatophyte infection)
• Pseudohyphae and budding yeast (Candida infection)
• Fragmented hyphae and spores (tinea versicolor)
 DIAGNOSTIC TECHNIQUES:
• TZANCK SMEAR:
– A cytologic technique used in the diagnosis of herpes virus infections
(simplex or varicella zoster)
– An early vesicle is unroofed, and the base of the lesion is scraped gently
with a scalpel blade, placed on a glass slide, air-dried and stained with
Giemsa or Wright’s stain
– Multinucleated epithelial giant cells suggest the presence of herpes, but
culture or immunoflourescence testing must be performed to identify the
specific virus

• DIASCOPY:
– Used to assess whether a skin lesion will blanch with pressure as, for
example, in determining whether a red lesion is hemorrhagic or simply
blood-filled
– Performed by pressing a microscope slide or magnifying lens against a
lesion and noting the amount of blanching that occurs
 DIAGNOSTIC TECHNIQUES:
• WOOD’S LIGHT:
– A Wood’s lamp generates 360-nm ultraviolet (or “black) light
that can be used to aid the evaluation of certain skin disorders
• Corynebacterium minutissimum- coral red color
• Tinea capitis (Microsporum canis or M. audouini)- yellow
flourescence
• Accentuates pigmented lesions of the dermis (freckles)
• Dermal pigment (post-inflammatory hyperpigmentation)
fade under a Wood’s light
• Vitiligo- appears totally white under a Wood’s lamp
• Tuberous sclerosis- demonstrate ash leaf spots
 DIAGNOSTIC TECHNIQUES:
• PATCH TEST:
– Designed to document sensitivity to a specific antigen
– A battery of suspected allergens is applied to the
patient’s back under occlusive dressings and allowed
to remain in contact with the skin for 48 hours
– The dressings are removed , and the area is examined
for evidence of delayed hypersensitivity reactions
(e.g., erythema, edema or papulovesicles)