HOW TO DEAL WITH A

DERMATOLOGICAL CASE

Functions of Skin
Skin is the largest organ of the body since:

◼ In the average adult it covers about 3000 square inches

◼ Human skin weighs around 2.7 kilogram, which is nearly double the weight of the
human brain or liver.

◼ The skin receives about 1/3 of the blood that circulates through the body

Functions of skin:

1. Protection: against any injury either mechanical as stab wound or thermal as hot objects or
chemical as acids
2. Temperature regulation: through skin sweating
3. Sensation: all types of sensations are felt via skin
4. Excretion: minute amounts of urea and uric acid are excreted via sweat
5. Synthesis of vitamin D: pro-vitamin D is converted to vitamin D on exposure to UVR in the
skin
6. UVR Screening: melanin in the skin reflect the UVR and protect the internal organs
7. Regulation of blood pressure: this is achieved via the arteriovenous shunts in the skin
8. Absorption: of systemic medication can be administrated via the skin as in nicotine patch
9. Psychogenic function: skin is the mirror of the body feeling. Fear may induce hair erection

For management of a dermatological disease, certain items must be fulfilled;

1- History taking

2- Clinical examination

3- Investigations (if needed)

4- Treatment

History Taking

1-Personal History:

A) Name: for patient identification

B) Age & sex: certain diseases occur in certain age and sex. (acne in adolescent & C.T diseases
are more common in females)
C) Occupation: skin exposed to external environment. (house wives eczema)

D) Residence: endemic disorder such as leprosy in upper Egypt & cutaneous leishmaniasis in
Iraq

2-Present History:

A) Complaint: may be disfigurement, itching or burning sensation.

B) Onset: acute, chronic or acute exacerbation on top of chronic illness.

C) Course: progressive, stationary or regressive.

3-Past History:

Important in recurrent disorders as recurrent herpes simples

4-Family History:

Important in congenital and infestation disorders (as ichthyosis & Scabies)

5-Drug History:

Drugs taken before appearance of the disease may cause drug eruption

B) Clinical Examination

1- General examination:

Skin disorders associated with systemic disorders as leprosy may be associated with
hepatosplenomegaly and lymph adenopathy

2- Local examination:

I) Examination of skin:

1- Examination from distance: to comment of skin lesion distribution

2- Close-up examination: to describe the details of skin lesions

II) Examination of skin appendages:

Mucus membranes, nails and hair.

Examination of the skin

A) From distance:
Shows the distribution of lesions that may be:
 1) Discrete distribution: multiple lesions separated from each other by
normal skin with bizarre arrangement
2) Unilateral distribution:
Lesions involving only one side of the body.
3) Generalized distribution:
Lesions involving more than 50% of body surface area.
4) Grouped distribution:
Lesions are restricted to a localized area.
5) Linear distribution:
Lesions are arranged a long a line. It may be Kobner`s phenomenon
which is appearance of isomorphic lesions along the site of blunt
trauma.
6) Zosteriform distribution:
Lesions are restricted to certain dermatome.
7) Follicular distribution:
Lesions are arranged along hair follicles.
B) Close-up examination

Shows the border of lesions that may be:

1) Well defined border:

Marked separation between the edge of the lesion and normal skin.

2) Ill defined border:

Difficult to identify the separation line between the lesion and normal skin.

3) Circinate border:

The lesion increases in size by peripheral extension and healing at the centre.

Types of Skin Lesions

Skin lesions may be:

1-Initial (primary) lesions.

2-Secondary lesions.

3-Specific lesions.

Initial Skin Lesions

A-Macule & patch

B-Papule & plaque

C-Nodule

D-Vesicle & Bulla

A) Initial Lesions

1) Macule:

It is discolouration of skin less than one cm in diameter. If larger than one cm, it is called patch.

2) Papule:

Solid elevation of the skin less than one cm in diameter. If more than one cm, it is called plaque

Types of Papule

a) Dome shaped:

Papule with smooth convex surface.

b) Flat topped:

Papule with flat surface. It is described as lichenoid papule.

c) Umbilicated:

Dome shaped papule with central notch.

d) Verrucous papule:

Papule with fine mammilated surface.

3) Nodule:

Elevated solid skin lesion with dermal extension. Usually better felt than seen.

4) Vesicle:

Fluid containing lesion less than one cm in diameter. If larger than one cm, it is called bulla. The
bulla may be tense or flaccid. The flaccid bulla is intraepidermal so it has a thin wall while the
tense bulla is subepidermal so it has a thick wall.

B) Secondary Lesions

1) Pustule:
It is elevated fluid filled lesion containing pus.

2) Scales:

It is dry surface due to abnormal keratinization (differentiation of epidermal cells to form

keratin). when skin keratinization is rapid, keratin will accumulate and separate in thick masses
(scales).

Types of Scales:

a) Fine branny:

Fine scales that easy detached on scrapping. Example: pytriasis versicolor

b) Greasy:

Oily grey yellow scales. Example: seborrheic Dermatitis

c) Lamellar:

Multiple layers of scales. Example: psoriasis

d) Fish scales:

Scales are grayish brown and fixed in the center and free at the periphery. Example: ichthyosis

e) Collarette:

The scales are arranged in a circle as a flower. Example: pityriasis rosea

f) Horny (Keratotic):

Thick compact scales that are adherent. Example: Discoid LE

3) Crust:

It is dried exudates, either pus or blood.

4) Erosion:

It is loss of part of epidermis. It heals with normal skin.

5) Ulcer:

It is loss of the whole epidermis and part of dermis, it has characteristic edge. It heals with scar
tissue

6) Fissure:

It is longitudinal discontinuity of the skin.

7) Atrophy:

It is thinning of skin due to thinning of epidermis or dermis or both. Atrophic skin is thin,
wrinkled, transparent and fragile. Sometimes it is described as cigarette paper like.

8) Scar:

It is replacement of the skin by fibrous tissue.

9) Lichenification:

It is a descriptive term of 3 criteria:

A) Thickening of skin

B) Hyperpigmentation

C) Accentuated skin markings

Skin lichenification is a feature of chronic eczema

C) Specific Initial Lesions

1) Wheal:

It is specific to urticaria. It is edematous erythematous lesion which is migratory. It is transient, it

does not persist more than 30 minutes.

2) Scutulum (Sulphar Cup):

It is specific for favus (clinical type of tinea capitis). It is cup shaped structure with concavo-
convex surfaces, golden yellow in colour and stuck to scalp.

3) Comedone:

It is specific to acne.

It is either:

A) Black head: dome shaped papule, follicular in postion with central black spot.

B) White head: small dome shaped papule, follicular in postion without central black spot.

4) Tunnel (Burrow):

It is specific for scabies. It is a curved line due to burrowing of female mite to skin. It is linear
structure or slightly curved, 7-12 mm in length with two ends, one is a vesicle or papule and the
other one is blind.
5) Target lesion:

It is specific to erythema multiforme. It consists of 3 zones:

A) Central zone: cyanotic.

B) Intermediate zone: pale.

C) Outer zone: erythematous

6) Herald patch:

It is specific for Pityriasis rosea.

It is a patch that has 3 concentric zones:

A) Central zone: café au lait.

B) Peripheral zone: erythematous.

C) Intermediate zone: collaret scales.

Examination of Mucus Membranes

A) Examination of mucus membranes

The mucus membranes of mouth, eye, nose and genitalia are inspected for:

Erosions, Ulceration, Plaque, Pigmentation or White Streaks (Lace Like)

Examination of Nails

The nails of fingers and toes are inspected for:

Nail Pitting, Nail Discolouration, Paronychia (Nail Fold Swelling) or Nail Dystrophy

Examination of Hair

I) Hair loss: it is either:

1- Diffuse hair loss. Hair is lost from all scalp aspects.

2- Patchy or alopecia: Hair is lost from localized area, it may be

A) Non cicatrical: hair follicles are still intact and visible. The scalp morphology is normal.

B) Cictrical: hair follicles are destroyed and scalp morphology is abnormal.

II) Hair growth in abnormal sites (bear area or trunk) in females. It is called hirsutism.
 INVESTIGATIONS

Immunoflourescent Tests:

They are used for diagnosis of autoimmune disorders. They are either:

1- Direct test:

It detects antibody in the skin. Skin biopsy is taken and flourescent anti-antibody is placed on it.

2- Indirect test:

It detects antibody in the serum of patient. Flourescent anti-antibody is added to the serum of
the patient.