TRANSCRIBED BY: LUKE, LEIA, HAN, CHEWBACCA

Page 1 of 4

Alfredo Guzman, MD

The adrenaline and stress of an adventure are better than a thousand peaceful days. Paulo Coelho Paulo Coelho

Assessment of the Skin and Lesions

1.1.2 02 June

2014

SKIN LESIONS

COMPOSITION OF A USEFUL SKIN EXAMINATION

Morphology (shape of the lesion)

Configuration (arrangement of lesions)

Distribution (Which body site)

MORPHOLOGICAL CLASSIFICATION OF LESIONS

Primary Skin Lesions unmodified lesions

Secondary Skin Lesions modified by scratching or infections

TECHNIQUES OF EXAMINATION

* additional notes from Bates Guide to Physical Examination and History Taking 1. Ensure that the patient wears a gown and is draped accordingly to facilitate close inspection of the following:

Hair Anterior and posterior surfaces of the body Palms and soles Web spaces between the fingers and toes

2. Inspect the entire skin surface in good light, preferably natural light or artificial light that resembles it

Artificial light often distorts colors and masks jaundice. 3. Correlate your findings with observations of the mucuos membranes, especially when assessing skin color, because diseases may appear in both areas

SKIN

A. COLOR 1. Ask if patient observed a change in skin color.

Increased pigmentation (browness) Loss of pigmentation Redness Pallow Cyanosis Yellowing of skin

2. Assess the red color of oxyhemoglobin and the pallor in its absence where the horny layer of the epidermis is thinnest and causes the least scatter.

Fingernails, lips, mucous membranes of mouth and palpebral conjunctiva In dark people inspecting palms and soles may also be useful CENTRAL CYANOSIS best defined in the lips, oral mucosa and tongue

3. Look for the yellow color of jaundice in sclera. May also be seen in palpebral conjunctiva, lips, hard palate, undersurface of tongue, tympanic

membrane, skin To see jaundice in the lips, blanch out the red color by pressure of glass slide. Yellowness associated with high levels of carotene (carotenemia), assess palms, soles, and face.

B. MOISTURE Dryness, sweating, and oiliness C. TEMPERATURE 1. Use back of fingers to make general assessment. 2. Note the temperature in any red areas. D. TEXTURE roughness and smoothness E. MOBILITY AND TURGOR

Lift the skin and note the following: o Ease with which it lifts up Mobility o Speed with which it returns into place Turgor

F. LESIONS EVALUATING BEDBOUND PATIENTS

Assess patient by inspecting the skin that overlies the scrotum, buttocks, greater trochanters, knees, and heels.

Pressure sores caused by sustained compression that obliterates arteriolar and capillary blood flow to the skin.

HAIR

Inspect and palpate hair. Note its quantity, distribution, and texture.

NAILS

Inspect and palpate the fingernails and toenails. Note the color, shape, and any lesions. Longitudinal bands of pigment normal in people with dark skin

I. PRIMARY SKIN LESIONS

GENERAL

CHARACTERISTIC

CLASSIFIED AS

DESCRIPTION

EXAMPLE

FLAT

MACULE

change in skin color

up to 1 cm

cannot be palpated

freckles, neurofibromatosis with caf au lait macules, hypopigmented macules and patch, vitiligo;

hemangioma PATCH

If macule is greater than 1 cm

RAISED (SOLID)

PAPULE

solid raised lesion with distinct borders

less than 1 cm in diameter

may have a variety of shapes in profile (domed, flat-topped, umbilicated)

may be associated with secondary features: crusts or scales

scabies, molluscum contagiosum, Id reaction to fungal infection, papulosquamous lesions (buni)

NODULE

a raised solid lesion more than 1 cm

it may be in the epidermis, dermis, or subcutaneous tissue

basal cell cancer, nodule in the axilla (lymph node in cat scratch fever)

TUMOR

a solid mass of the skin or subcutaneous tissue

larger than a nodule

not necessarily a neoplasm

AV malformation, xanthomas

PLAQUE

a solid, raised, flat-topped lesion greater than 1 cm in diameter.

it is analogous to the geological formation, the plateau

tuberous sclerosis, psoriasis

TRANSCRIBED BY: LUKE, LEIA, HAN, CHEWBACCA

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Skin and Lesions

II. SECONDARY SKIN LESIONS

CLASSIFICATION

DESCRIPTION

EXAMPLE

1. SCALE

consists of flakes or plates that represent compacted desquamated layers of stratum corneum.

desquamation occurs when there are peeling sheets of scale following acute injury to the skin.

Exfoliation of epidermis

seborrheic dermatitis, tinea capitis (poknat), Kawasaki disease

cradle cap among infants may signify that infant is prone to allergy and skin disease when he/she grows up

2. CRUST

result of the drying of plasma or exudate on the skin.

Note: Please remember that crusting is different from scaling. The two terms refer to different phenomena and are not interchangeable. One can usually be distinguished from the other by appearance alone.

peri-oral lesions in impetigo (honey colored adherent crust)

3. ATROPHY

thinning or absence of the epidermis or subcutaneous fat

(-) hair, sweat and oil due to lack of sebaceous and sweat glands

linear areas of atrophy (striae) secondary to chronic systemic steroid administration; result of advanced graft vs. host disease.

4. LICHENIFICATION

refers to a thickening of the epidermis seen with exaggeration of normal skin lines.

It is usually due to chronic rubbing or scratching of an area.

pruritic scabies usually in the web spaces between fingers

tx: use anti-itch creams

5. EROSION

are slightly depressed areas of skin in which part or all of the epidermis has been lost

consequences of a self-inflicted chemical burn, associated with Stevens-Johnson syndrome

in SJS all epidermal cells are affected: GI and visceral cells, so px is given antiulcer medications

6. EXCORIATION are traumatized or abraded skin caused by scratching or rubbing.

swimmers itch

7. FISSURE

linear cleavage of skin which extends into the dermis a fissure at the angle of lips as a consequence of Kawasaki disease

8. ULCERATIONS

occur when there is necrosis of the epidermis and dermis and sometimes of the underlying subcutaneous tissue.

extensive ulceration of her lips after having chewed on a live electrical wire

9. SCAR

Permanent fibrotic changes that occur on the skin following damage to the dermis.

Shiny, dry , thin

may have secondary pigment characteristics

10. ESCHAR

a hard plaque covering an ulcer implying extensive tissue necrosis, infarcts, deep burns, or gangrene

look like very big ulcers

meningococcemia

11. KELOIDS

an exaggerated connective tissue response of injured skin that extend beyond the edges of the original wound.

keloid at the site of an old lymph node biopsy site

12. PETECHIAE, PURPURA,

ECCHYMOSES (Bruise)

three terms that refer to bleeding that occurs in the skin

easy bruising in unlikely areas

PETECHIAE - smaller lesions > DO NOT BLANCH

petechiae from thrombocytopenia secondary to chemotherapy, purpura associated with the disease Henoch-Schnlein Purpura, suction purpura caused by the medical practice of cupping which has its origins in antiquity, purpura and ecchymosis on the skin as presenting symptoms of acute myelogenous leukemia

PURPURA & ECCHYMOSES- larger

lesions > DO NOT BLANCH

HOW TO DIFFERENTIATE A PALPABLE PURPURA FROM A RASH: press on the lesions carefully with a glass slide; purpura do not blanch when pressed

III. DISTRIBUTION OF SKIN LESIONS

DISTRIBUTION DESCRIPTION EXAMPLE

I. PRIMARY SKIN LESIONS

RAISED (FILLED)

VESICLES

raised lesions less than 1 cm in diameter that are filled with clear fluid

hand, foot, and mouth disease

BULLAE

circumscribed fluid-filled lesions that are greater than 1 cm in diameter

Stevens-Johnsons Syndrome, Contact dermatitis, severe allergy

PUSTULES

circumscribed elevated lesions that contain pus

most commonly infected (as in folliculitis) but may be sterile (as in pustular psoriasis)

group A beta-hemolytic streptococcus infection

OTHERS

WHEAL area of edema in the upper epidermis urticaria (hives), insect bites

BURROWS

linear lesions produced by infestation of the skin and formation of tunnels

with infestation by the scabitic mite (galis aso) or by cutaneous larva migrans

TELANGIEC- TASIA

permanent dilatation of superficial blood vessels in the skin

may occur as isolated phenomena or as part of a generalized disorder, such as ataxia telangiectasia

spider or starburst telangiectasia

TRANSCRIBED BY: LUKE, LEIA, HAN, CHEWBACCA

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Skin and Lesions

1. PHOTODISTRIBUTED on areas exposed to the sun face, neck, decolette, dorsal part of feet

2. INTERTRIGINOUS

on areas where skin rub each other; often wet and irritated

along creases and fold

axillary area

inguinal area

inframammary fold

3. LYMPHANGITIC

along the path of lymph channels of leg or arm leg and arm lymph path

fungal infection: sporotrichosos

4. DERMATOMAL area of skin following sensory innervations of a particular nerve root

does not cross midline of body

T4 along nipple line

C5- along shoulder

Herpes zoster

5. PALMS AND SOLES Along palms and soles. You dont say.

V. PATTERNS OF SKIN LESIONS

PATTERNS DESCRIPTION EXAMPLE

1. ANNULAR

seen in a ring shape Tinea corporis

erythema migrans (the lesion associated with lyme diseas

granuloma annulare

2. DISCRETE

tend to remain separate

has little specific diagnostic significance

vesicles of varicella in a discrete pattern

3. CLUSTERED

are grouped together commonly seen in herpes simplex or with insect bites

4. CONFLUENT

tend to run together macular lesions of Kawasaki disease

Dengue Hemorrhagic Fever

5. DERMATOSOMAL

/ZOSTERIFORM

follow a dermatome The lesions of varicella zoster (also known as shingles); other lesions may assume the same pattern

6. ECZEMATOID

inflamed with a tendency toward clustering, oozing, or crusting atopic dermatitis

7. FOLLICULAR

lesions that specifically involve the hair follicle keratosis pilaris

8. GUTTATE

look as though someone took a dropper and dropped this lesion on the skin

Guttate lesions are characteristic of one form of psoriasis, though that is not the only example

9. IRIS OR TARGET LESIONS

look like the bulls eye in dartboards erythema multiforme

Kawasaki disease

10. KOEBNER PHENOMENON

also called the isomorphic response

the appearance of lesions along a site of injury o Auspitz sign

tiny bleeding points (due to suprapapillary thinning) when you remove a scale from psoriasis lesion

o Dariers sign when you stroke lesion of urticaria pigmentosa (form of cutaneous mastocytosis) erythema & edema (due to mast cell degranulation with

histamine release) o Nikolsky sign

when you rub normal skin beside blister induction of new blister

seen in pemphigus vulgaris and toxic epidermal necrolysis(ten)

o Dermatographism when you stroke the normal skin edema and erythema

(you can write on skin!) seen in physical urticaria

lichen planus

warts

molluscum contagious

psoriasis

lichen nitidus

systemic form of juvenile rheumatoid arthritis

11. LINEAR occur in a line or band-like configuration.

term may apply to a wide variety of disorders

one should be certain that the lesions are not following a dermatome

linear streaking associated with the lesion of lichen striatus, poison ivy dermatitis

lymphangitis with linear streaking following the line of the lymph system

12. MULTIFORM lesions of a variety of shapes erythema multiforme

13. RETICULAR

net-like lesions

can be seen in a variety of circumstances

very commonly in newborns (or even grown children and adults) as cutis marmorata, or with livedo reticularis. The former fades as the skin is warmed the latter becomes more florid

14. SERPIGINOUS wander as though following the track of a snake urticaria following a serpiginous route

15. UNIVERSALIS

refers to a widespread disorder that affects the entire skin

alopecia universalis (patient with complete absence of hair on his body, including the absence of eyelashes and eyebrows)

16. SCARLATINIFORM

have the pattern of scarlet fever

the patient with a scarlatiniform rash has innumerable small red papules that are widely and diffusely distributed

note that the term scarlatiniform does not mean that the patient has scarlet fever, although by definition all patients with scarlet fever have a scarlatiniform rash.

Kawasaki disease, viral infections, or drug reactions

17. STRAWBERRY TONGUE

distinctive appearance in the tongue among patients with scarlet fever, Kawasaki disease or other conditions

because of its resemblance to the well-known berry, the appearance is called "strawberry tongue."

scarlet fever

Kawasaki disease

TRANSCRIBED BY: LUKE, LEIA, HAN, CHEWBACCA

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Skin and Lesions

since this eruption is on a mucus membrane, it is called an enanthem

18. MORBILLIFORM

a rash that looks like measles

patients with measles will have the rash but patients with Kawasaki disease, drug reactions, or other conditions may also have a morbilliform rash.

consists of macular lesions that are red and are usually 2-10 mm in diameter but may be confluent in places

measles

drug reaction to Dilantin

19. SATELLITE

a portion of the rash of cutaneous candidiasis in which a beefy red plaque may be found surrounded by numerous, smaller red macules located adjacent to the body of the main lesions

candidal diaper dermatitis

20. PATTERNS OF

INTENTIONAL/UNINTENTIONAL INJURY

in cases of child abuse or other intentional injury (bite marks, slap marks, strap marks, burns, etc.) or in cases of unintentional injury

abrasions are traumatically caused erosions

rollerblading mishap

cigarette burn

linear ecchymosis from car crash

Battle sign: sign of basilar skull fracture; bruising behind the ear

VI. COLOURS IN DERMATOLOGY

RED Vascular lesions e.g. port wine stain; inflammatory disorders (psoriasis)

BLUE Blue nevus; Mongolian spot

YELLOW Xanthoma: deposition of yellow cholesterol rich material on tendons/ other body parts

WHITE Vitiligo: Michael Jackson

BLACK Melanocytic nevus ; melanoma

PURPLE/ VIOLACEOUS Lichen planus

VII. CONFIGURATION

Configuration Disease Figure

Flat-topped Lichen planus

Dome-shaped Lymphomatoid

papulosis

Slightly elevated Panniculus

Acuminate Acute spongiotic

dermatitis

Papillated Intradermal nevus

Digitated Wart

Umbilicated Molluscum

contagiosum