Systemic Examination

Hands & Elbows

 Nail pitting:, psoriasis and alopecia areata., Onycholysis: psoriasis and fungal nail infection. Koilonychia: (e.g. malabsorption in Crohn’s)
 Inspect the elbows for evidence of psoriasis plaques, xanthomas (hyperlipidaemia) or rheumatoid nodules (rheumatoid arthritis).

Hair & Scalp

 Alopecia areata: well-defined patches of hair loss with surrounding normal hair.
 Alopecia totalis: loss of all hair from the scalp.
 Hirsutism: androgen-dependent excess hair growth in females.
 Hypertrichosis: non-androgen-dependent excess hair growth.
 Scalp psoriasis: plaques of psoriasis located on the scalp, often resulting in visible scale in the hair.
 Seborrhoeic dermatitis: often causes diffuse scale to be present throughout the scalp.

Mucous Membranes

 Hyperpigmented macules: pathognomonic for Peutz-Jeghers syndrome, an autosomal dominant genetic disorder that results in the development
of polyps in the gastrointestinal tract.
 Bullae: associated with bullous pemphigoid, and pemphigus vulgaris, both autoimmune blistering disorders.
 Whickham’s striae: a sign of lichen planus and can be in the buccal mucosa, but also on the genital skin.
Skin Cancers
Basal Cell Carcinoma
 BCC is a slow-growing, locally invasive epidermal skin tumour arising from the basal cell.
 Low-risk subtypes – nodular (nBCC), superficial (sBCC)
 High-risk subtypes – morpheic/sclerosing, basosquamous (histologically differentiated)
 Diagnosis of condition is made clinically with sub-classification made histologically

Clinical Descriptors

 NBCC usually presents as a pearly (shiny) nodule with telangiectasia on the head and neck region; it tends to
ulcerate with time and result in a rolled edge.
 SBCC usually presents as a slow-growing erythematous patch or plaque that is usually found on the trunk.

Management

 Surgical excision with histological assessment – Target excision margin depends on the subtypes (3mm for nBCC).
 Radiotherapy can be used as an adjuvant for primary and recurring BCC
 Mohs micrographic surgery is used in high risk facial BCC’s

Squamous Cell Carcinoma

 SCC is cutaneous carcinoma arising from the keratinocytes of the epidermis or its appendages.
 Actinic Keratosis (partial epidermal) & Bowens (full epidermal) are precursors, SCC invades beyond the
basement membrane
 Diagnosis of condition is made clinically with sub-classification made histologically

Clinical Descriptors

 indurated keratinising or crusted plaque or nodule at sun-exposed sites (e.g. dorsal hands and forearms,
face)
 The lesion is typically symptomatic (e.g. pain, discomfort, bleeding, ulcerating, sensory changes)
 SCCs have different morphologies – well differentiated (less aggressive), poorly differentiated (more
aggressive).

Management

 Surgical excision (margin of 4mm for low-risk & 6mm for high risk tumours.
 Mohs surgery used in high risk tumours
 Curettage, cautery in small, well-defined tumours
 Adjuvant radiotherapy
 Advise use of suncream
Melanoma
 Melanoma is a malignant tumour arising from melanocytes.
 Highest risk of malignancy

Classification & descriptors

 Predominantly radial growing – superficial spreading melanoma (SSM), acral lentiginous melanoma
(ALM), lentigo maligna melanoma (LMM) or lentigo maligna if it is in situ – Follows the ABCDE rule
o Has potential to progress into vertical growth phase, which carries higher metastatic risks.

 Predominantly vertical growing – nodular melanoma (NM) – May not exhibit ABCDE features and
follows the EFG rule: E – Elevation, F – Firm, G – Growing – Prognosis is poorer as vertical growth
phase starts earlier

Investigations

 Excisional biopsy with a 2mm margin is GOLD STANDARD (punch or excisional done on the face)
 BRESLOW THICKNESS, Clark Level, lymphatic invasion, presence of ulcers, mitotic invasion
o Stage IV: when there is organ metastasis
o Stage III: when there is lymph node involvement (Stage IIIA is when there is 1–3 nodal
micrometastases but without ulceration)
o Stage II: when BT >2mm or BT 1.01–2mm with ulceration
o Stage I: when BT <1mm or BT 1.01-2mm without ulceration
 Stage IIIB> CT staging

Management

 Surgical excision is the gold standard treatment. The recommended surgical margin is:
o 5mm for in situ melanoma
o 1cm for Breslow thickness <1mm
o 1-2cm for BT 1.01-2mm
o 2-3cm for BT 2.1-4mm
o 3cm for BT >4mm
 Radical lymph node dissection in metastatic
 Chemo and radio used in a reserved manner.
 Patients advised to use sun protection.
Dermatological History

Introduction & Consent

Presenting Complaint

 Nature, site?
o Flexor compartments? Photosensitive areas? Scalp?
 SOCRATES/ OPERA
o Evolution of lesion?
o Exacerbating; shower gels & soaps? work? Pets?
o Relieving; Away from work? Pets?
o Previous & current treatments (effective or not)
o Previous episodes? What helped to resolve it?
o Symptoms;
 Itch? inflamed (red & swollen)? pain? Swelling? Fluids? Rash? Bleeding? Discharge? Blistering? Rash?
 Systemic: Fever? Malaise? Weight loss? Joint Pain?
 Recent contact? ⇒ infection, travel, outbreaks in school
 Stressful events?
 Jewellery
o Rings, bracelet, necklace (NICKEL exposure)
 Sun exposure?
o Recent holidays? Worked away in the sun? Outdoor job? Sunbeds?

Past Medical History

 Living with any conditions? Been hospitalised?

 History of... Eczema? hayfever?, asthma?
 History of skin cancers or suspicious lesions?

Family History

 Family history of any skin diseases... Eczema? Psoriasis? Skin cancers? Rheumatoid arthritis

Drug History

 Prescriptive drugs?
 Over the counter medications?
 Creams?
 Herbal remedies?
 Drug allergies? or any allergies (e.g latex)

Social History

 Drink, Alcohol, Illicit drugs

 Occupation ⇒ stressful
o Improvement of lesions away from work?
o Outdoors? Travelling?
 Housing?
 Family support

Systemic, ICE & Summary

 Systemic: fevers (e.g. cellulitis)

 Cardiovascular: peripheral oedema, limb ischaemia (PAD)