Evaluation of Skin Disorders

A

History and Physical Examination

• The initial step in the dermatologic evaluation involves obtaining a detailed dermatologic history. Box 1.1 describes pertinent questions.

  BOX 1.1

  Dermatologic History

  From Goldstein BG, Goldstein AO: Practical Dermatology, ed 2, St. Louis, 1997, Mosby.

  A

  Initial Questions

  • 1.

    When did the rash start?

  • 2.

    What did it look like when it first started, and how has it changed?

  • 3.

    Where did it start, and where is it located now?

  • 4.

    What treatments, especially over-the-counter medications or self-remedies, has the patient tried? What was the effect of each of these treatments?

  • 5.

    Are there symptoms (e.g., itching, pain)?

  • 6.

    What is the patient’s main concern about the rash (e.g., itching, pain, cancer)?

  • 7.

    How is the rash affecting the patient’s life?

  • 8.

    Are other family members concerned or affected?

  • 9.

    Has the patient ever had this rash before? If so, what treatment worked?

  • 10.

    What does the patient think caused the rash?

  B

  Follow-up Questions

  • 1.

    Does the patient have a history of chronic medical problems?

  • 2.

    What is the patient’s social history, including occupation (chemical exposures), hobbies, alcohol and tobacco use, and any underlying interpersonal or family stress?

  • 3.

    What medications is the patient taking, acutely or chronically, including birth control pills and over-the-counter medications?

  • 4.

    Does the patient have any underlying allergies?

  • 5.

    Is there a family history of hereditary or similar skin diseases?

  • 6.

    Will the patient’s education or financial status influence treatment considerations?

• When examining the patient, it is essential to accurately and concisely describe the skin lesions, their distribution, and their overall characteristics.

• Skin lesions should be classified as primary or secondary:

  • Primary lesions represent the initial lesional morphology, and are critical to recognize in order to reach an accurate diagnosis.

  • Secondary lesions may result from evolution or chronicity of the primary lesion, or may be created by scratching, infection, and other secondary skin changes.

• The proper terminology in describing these lesions is described in Boxes 1.2 and 1.3 .

  BOX 1.2

  Primary Skin Lesions

  From Goldstein BG, Goldstein AO: Practical dermatology , ed 2, St. Louis, MO, 1997, Mosby.

  • Macule : Small spot, different in color from surrounding skin, that is neither elevated nor depressed below the skin’s surface

  

  • Papule: Small (≤5 mm diameter) circumscribed solid elevation of skin

  

  • Plaque: Large (≥5 mm) superficial flat lesion, often formed by a confluence of papules

  

  • Nodule: Large (5–20 mm) circumscribed solid skin elevation

  

  • Pustule: Small circumscribed skin elevation containing purulent material

  

  • Vesicle: Small (<5 mm) circumscribed skin blister containing serum

  

  • Wheal: Irregular elevated edematous skin area, which often changes in size and shape

  

  • Bulla: Large (>5 mm) vesicle containing free fluid

  • Cyst: Enclosed cavity with a membranous lining, which contains liquid or semisolid matter

  • Tumor: Large nodule, which may be neoplastic

  • Telangiectasia: Dilated superficial blood vessel

  BOX 1.3

  Secondary Skin Lesions

  From Goldstein BG, Goldstein AO: Practical dermatology , ed 2, St. Louis, MO, 1997, Mosby.

  • Scale: Superficial epidermal cells that are dead and cast off from the skin

  

  • Erosion: Superficial, focal loss of part of the epidermis; lesions usually heal without scarring

  

  • Ulcer: Focal loss of the epidermis extending into the dermis; lesions may heal with scarring

  

  • Fissure: Deep skin split extending into the dermis

  

  • Crust: Dried exudate, a “scab”

  

  • Erythema: Skin redness

  • Excoriation: Superficial, often linear skin erosion caused by scratching

  • Atrophy: Decreased skin thickness due to skin thinning

  • Scar: Abnormal fibrous tissue that replaces normal tissue after skin injury

  • Edema: Swelling due to accumulation of water in tissue

  • Hyperpigmentation: Increased skin pigment

  • Hypopigmentation: Decreased skin pigment

  • Depigmentation: Total loss of skin pigment

  • Lichenification: Increased skin markings and thickening with induration secondary to chronic inflammation caused by scratching or other irritation

  • Hyperkeratosis: Abnormal skin thickening of the superficial layer of the epidermis

• For diagnostic purposes, it is also important to note the distribution of the skin lesions, as many dermatologic conditions present in characteristic anatomic locations or in specific configurations.

• Table 1.1 describes vascular and miscellaneous skin dermatoses.

  TABLE 1.1

  Vascular Skin Lesions

  From Swartz MH: Textbook of physical diagnosis: history and examination , ed 6, Philadelphia, 2010, Saunders.

  Lesion	Characteristics	Examples
  Erythema	Pink or red blanchable discoloration of the skin secondary to dilatation of blood vessels	Facial flushing
  Petechiae	Reddish-purple; nonblanching; smaller than 0.5 cm	Intravascular defects
  Purpura	Reddish-purple; nonblanching; greater than 0.5 cm	Intravascular defects
  Ecchymosis	Reddish-purple; nonblanching; variable size	Trauma, vasculitis
  Telangiectasia	Fine, irregular dilated blood vessels	Dilatation of capillaries
  Spider Angioma	Central red body with radiating spider-like arms that blanch with pressure to the central area	Liver disease, estrogens

  Miscellaneous Skin Lesions
  Lesion	Characteristics	Examples
  Scar	Replacement of destroyed dermis by fibrous tissue; may be atrophic or hyperplastic	Healed wound
  Keloid	Elevated, enlarging scar growing beyond boundaries of wound	Burn scars
  Lichenification	Roughening and thickening of epidermis; accentuated skin markings	Atopic dermatitis

B

Dermatoses by Anatomic Region