SKIN IN CLINICAL

DIAGNOSIS
DR OLANREWAJU FALODUN(FMCP)
Outline
Introduction
Embryology
Structure of skin.
Approach to skin in clinical diagnosis
Conclusion
Introduction
The skin is the largest organ in the body.
It plays a vital role in protecting other body organs from harm.
It also helps with other functions including temperature regulation among others.
The need for proper dermatological examination cannot be overemphasized as will be discussed
subsequently in this lecture.
Basic embryology of skin
Development of skin starts at 4th-5th week of gestation and consists of a single layer of ectoderm
overlying mesoderm
The single layer of ectoderm is called primordium which eventually forms squamous epithelium.
periderm and basal layer.
Periderm cells desquamate +sebum from sebaceous glands .Vernix caseosa.

Basal layer will form intermediate layer , differentiates later into stratum germinativum
Neural crest cells migrate into mesenchyme of the dermis and differentiates into melanoblasts
& later migrate to dermoepidermal junction to differentiate into melanocytes.
Dermis develops from mesoderm.

When epidermal ridges form ,the dermis projects into epidermis. Capillary loops develop in
some while sensory nerve endings form in other ridges.
Sebaceous glands from epidermal root sheaths

Sweat glands: Eccrine G develop as epidermal downgrowth.

Apocrine glands: down growth of stratum germinativum

Hair: begins 9th -12th week. First sites of hair growth are eyebrow, upper lip, chin. Hair begins as
a proliferation of starum germinativum.
Nails: toe nails and finger nails begin at 10week, finger nails preceed toenails by 4weeks.
Primordia of nails appear as thickened area of epidermis called field. Nail fields migrate into
dorsal surface of the distal phalanx.
At the beginning ,nail plate is covered by superficial layer of epidermis called eponychium.
Skin structure
The skin has three major layers: Epidermis , dermis and subcutaneous tissue.

Epidermis has 5 layers: from above, Stratum corneum, stratum lucidum, stratum granulosum,
stratum spinosum and stratum germinativum(stratum basale).Stratum lucidum is found in palms
and soles of feet.
The Dermis: connective tissue ,blood vessels, sweat glands, nerves, hair follicles. Essentially for
support ,thermoregulation, and aids in sensation.

The subcutaneous tissue: Also called hypodermis. Insulates the body, stores energy and
connects the skin to muscles and bones.
Skin Structure
Approach to skin examination
The clinician should not trivialize skin examination because vital details can be obtained from a
well carried out skin examination.

A number of times clinical details obtained from dermatological examination can help raise
suspicion of an underlying systemic disorder or of a dermatologic disorder that is a component
of a syndrome.
Approach to Skin Examination (contd)
Morphology: macule, patch, papule, nodule.
Size: >1cm , <1cm
Demarcation: well demarcated, not well demarcated
Colour: white, red, black
Secondary morphology: serum (dry crust), fissure, lichenification, ulceration, ulceration, scaling.
Distribution: extensor ,flexor, photodistributive.
Adequate exposure is important in dermatological examination.

Examination of the skin should always be carried out in a room with good lighting.

Always remember to examine the scalp/hair and nails so that important findings are not
missed.
Skin pigmentary Changes
Generalised or localized
Generalised hyperpigmentation :
Haemochromatosis- grey or brownish
Addisons disease-generalized hyperpigmentation with accentuation on the palmar creases,
scars, bony prominences
Localised Hyperpigmentation:
Macular palmar hyperpigmentation, which may involve nails: Vit B12 deficiency, Chronic liver
disease
Hypopigmention :May be generalized or localized

Generalised Hypopigmentation : albinism which may have other syndromes accompanying it.
Chediak –Higashi Syndrome, Hermansky –Pudlack Syndrome, Griscelli Syndrome.

Localised Hypopigmentation: acquired e.g vitiligo which may be a pointer towards other
autoimmune conditions e.g. pernicious anaemia, diabetes mellitus , thyroiditis etc.
FDE
Hyperpigmented usually circumscribed patches on the skin. At times bullae may form.

Usually a reaction to a drug.

Recurs at same site each time the drug or related drug is taken.
The key is a good history to identify the drug.

At times difficult because of multiple drug use.

Common drugs: barbiturates, sulfonamides, quinine , Aspirin

FDE
The paradox with FDE is such that if it is not suspected ,the individual might keep on taking
similar or same drugs to treat the lesions with adverse consequences.
Nail changes and systemic disorders
Nail abnormalities may form clues to systemic disease.

Visual appearance of fingernails and toe nails may suggest an underlying systemic disease.

Attention should be paid to examining the nails as valuable clues to a clinical diagnosis may be
seen.
Digital clubbing: inflammatory bowel disease, pulmonary malignancy, Arteriovenous
malformations, asbestosis, endocarditis, chronic bronchitis.
Kiolonychia: iron deficiency anemia, haemochromatosis, Raynauds disease, SLE, Nail patella
Syndrome.
Onycholysis: Psoriasis, hyperthyroidism, amyloidosis, connective tissue disorders, sarcoidosis.
Pitting: psoriasis, Reiters Syndrome, alopecia areata, incontinenta pigmenti.
Beau lines: severe systemic illness, Raynauds disease, pemphigus, trauma
Yellow nail: lymphedema, pleural effusion, Immunodeficiency, bronchiectasis, sinusitis.
Half and half nails: CKD
Splinter haemorrhages : infective endocarditis, , local trauma psoriasis.
HALF AND HALF NAILS IN A PATIENT WITH CKD
Oil drop sign : psoriasis in addition to pitting, yellow, white or brown
discolouration.

Melanonychia: Vit B12 def, sub ungal melanoma, drugs e.g. Zidovudine,
chloroquine.
Mouth /mucosal signs
Oral/oropharyngeal candidiasis: HIV infection

Snail track ulcers: Syphilis

Painful mouth ulcers: Behcets disease, herpes simplex(on lips)

Coloured plaques on hard or soft palate, gingiva or tongue, violaceus, brownish red colour-
Kaposi sarcoma in AIDS
PRURITUS
Pruritus is a common symptom in patients seeking dermatology review.

When pruritus comes with a rash, diagnosis can be made by examination of the rash.

Pruritus may not present with a rash and may be a symptom of internal disease.
Iron deficiency anaemia, polycythaemia, thyroid disease ,CKD , lymphomas
and Primary biliary cirrhosis are known causes of pruritus .

History and investigations should be with the aim of excluding any these
possibilities.
Alopecia
There are various types.
Male pattern : androgenetic only of cosmetic significance in males.

In females however other considerations PCOS, late onset CAH etc should be considered esp. if
other features like acne, change of voice are present
Alopecia Areata
Remember that T. Capitis is not usual in adults.

Why??
Fungistatic saturated fatty acids in sebum increases at puberty.

Alopecia +malar rash+ recurrent fever joint

pains: always consider autoimmune disease e.g. SLE.
Other diseases ;Thyroid, HIV infection, Nutritional Def e.g. Zinc , Vit C ,Kwashiokor.

Psychiatric :Trichotillomania
Psoriasis
The most characteristic lesions are well demarcated plaques with silvery scales.

Commonly on extensor surfaces and scalp.

5-10% of patients with psoriasis may develop

psoriatic arthritis.
It is an important differential diagnosis to consider in a patient with a rash and joint pains.

The rash also gives “koebners phenomenon”.

May appear around surgical wounds/sites or sites of trauma.

SCALP PSORIASIS
Nail Pitting in Psoriasis
Lichen planus
Characterised by “P”s: plentiful, pruritic, planar, polished, papules.

A known cause of rashes and ulcers in the mouth.

Also demonstrates Koebners phenomenon.

Associations have been reported between Lichen planus and Hepatitis C infection. Few Nigerian
studies done have not confirmed this.

Viral screening is still advocated.

SKIN and DM
A number of skin lesions are seen in Diabetes Mellitus.

Presence of some of these lesions may be an indication for DM screening in an individual who
has not been diagnosed.

Treatment of DM may make the skin lesion easier to treat.

Extensive P. versicolor
Candidiasis
Acanthosis Nigricans
Recurrent boils
Diabetic dermopathy
Bullous disease of diabetes
BULLOUS DISEASE
Acanthosis Nigricans
Pityriasis Versicolor
SKIN And CKD
Uraemic frost: rare nowadays
Pallor
Hyperpigmentation
Pruritus
Half and Half nails
Infections
Xerosis
Keratotic pits of palms and soles
Calcinosis cutis
Cutaneous infections
onychomycosis, tinea pedis.
Skin and Malignancies
Some skin lesions are associated with malignancies.

It is important not to focus on the lesion alone but also to screen for the internal malignancy as
may be indicated.
Sweet syndrome : leukaemia, breast, Colonic cancers
Erythema Gyratum repens:Lung cancer, breast, bladder, gastric cancer
Necrolytic migratory erythema: Glucagonoma
Paraneoplastic pemphigus:Leukaemia(CLL), multiple myeloma,NHL
Dermatomyositis; malignancy found in 8.5% of a subset.
Females :ovarian ca

(Callen J.P: Dermatomyositis Lancet 355:53-57,2000)

Seborrheic Keratosis
Usually only of cosmetic significance.

Sudden eruption of numerous lesions may suggest internal malignancy e.g. abdominal
carcinoma.

(Ceylan C et al:Int J Dermatol; 2002 41:687-688)

SEBORRHEIC KERATOSIS
Sezary syndrome
Sezary syndrome: Triad of findings
- Cutaneous erythema
-Lymhadenopathy
- 10-15% atypical mononuclear cells

Patients usually have pruritus.

Skin biopsy :CTCL
(Foss F:Mycosis fungoides and the sezary syndrome. Curr Opin Oncol 5:421-428,2004)
Patients usually have pruritus

Skin biopsy shows CTCL

Other features like hair loss , nail dystrophy may be present.

Sezary syndrome
Sezary syndrome: Triad of findings
- Cutaneous erythema
-Lymhadenopathy
- 10-15% atypical mononuclear cells

Patients usually have pruritus.

Skin biopsy :CTCL
(Foss F:Mycosis fungoides and the sezary syndrome. Curr Opin Oncol 5:421-428,2004)
Mycosis Fungoides
(Derm Atlas)
Acquired Icthyosis
Acquired ichthyosis has been associated with Hodgkins disease, T Cell lymphoma, leukaemia,
multiple myeloma etc.
Acquired Ichthyosis
SKIN IN HIV
A big topic on its own

It is important to note that some lesions may arouse the need for retroviral screening.

Whenever a lesion is exaggerated in presentation, or unusual in presentation a retroviral

screening should be considered.
Some lesions to consider in HIV
PPE
Molluscum contagiosum
Warts
Extensive Tinea
Proximal sub-ungal onychmycosis
Herpes zoster
TINEA CORPORIS
Herpes zoster in HIV
Extensive herpes zoster: multi dermatomal
Ulcerating with delayed healing
Post herpetic neuralgia
Herpes Zoster
Can you attempt a diagnosis???
Conclusion
It is possible to make diagnosis of hidden clinical conditions by thinking deeper than the skin
rash.

We should always strive to do a complete evaluation of our patients .

Always remember that the “subtle” or resolving rash may be a pointer to something within.
THANKS FOR LISTENING