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
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