Dermatologic Examination

Examination of the skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin is a fundamental part of the standard physical exam. This exam consists of a thorough inspection of the skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin of the entire body. The assessment focuses on identifying abnormal signs on the skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin, such as the scalp, orifices, nails, and mucosal surfaces. Dermatologic findings can represent localized processes or may be a sign of systemic disease.

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Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

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Terminology

Primary and secondary skin lesions Secondary Skin Lesions The identification and classification of a patient's skin lesions are important steps in the diagnosis of any skin disorder. Secondary lesions develop from irritated or manipulated primary lesions and/or manifestations of disease progression. Secondary Skin Lesions

Primary skin lesions Primary Skin Lesions The identification and classification of skin lesions in a patient are important steps in the diagnosis of any skin disorder. Primary lesions represent the initial presentation of the disease process. Primary Skin Lesions occur as a direct result of a pathologic process, while secondary skin lesions Secondary Skin Lesions The identification and classification of a patient's skin lesions are important steps in the diagnosis of any skin disorder. Secondary lesions develop from irritated or manipulated primary lesions and/or manifestations of disease progression. Secondary Skin Lesions are those that result from manipulation of the skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin.

Table: Primary skin lesions Primary Skin Lesions The identification and classification of skin lesions in a patient are important steps in the diagnosis of any skin disorder. Primary lesions represent the initial presentation of the disease process. Primary Skin Lesions
Primary skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin lesion Description
Macule
  • Flat, nonpalpable skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin lesion ≤ 1 cm in size
  • Differs in color from the surrounding skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin
Papule Small palpable skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin lesion ≤ 1 cm in diameter
Plaque Palpable, raised lesion > 1 cm
Nodule
  • Elevated lesion
  • > 1 cm in both diameter and depth
Vesicle Small fluid-containing blister ≤ 1 cm in diameter
Bullae Large fluid-containing blister > 1 cm in diameter
Pustule Vesicle filled with pus
Table: Secondary skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin lesions
Secondary skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin lesions Description
Scale
  • Thickened stratum corneum
  • Thin, flaky, dry, and white
Crust Dried exudates, such as pus or blood
Fissure
  • Linear crack through the epidermis extending to the dermis
  • Loss of continuity of the skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin
Ulcer
  • Break in the continuity of the epithelium Epithelium The epithelium is a complex of specialized cellular organizations arranged into sheets and lining cavities and covering the surfaces of the body. The cells exhibit polarity, having an apical and a basal pole. Structures important for the epithelial integrity and function involve the basement membrane, the semipermeable sheet on which the cells rest, and interdigitations, as well as cellular junctions. Surface Epithelium
  • Occurs owing to loss of epidermis and dermis
Erosion
  • Circumscribed depressed lesion due to loss of epidermis
  • Heals without scarring
Necrosis Dead skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin tissue
Atrophy
  • Thinning of the skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin
  • Skin becomes shiny and wrinkled
Scar Replacement of the skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin with fibrotic and connective tissue Connective tissue Connective tissues originate from embryonic mesenchyme and are present throughout the body except inside the brain and spinal cord. The main function of connective tissues is to provide structural support to organs. Connective tissues consist of cells and an extracellular matrix. Connective Tissue as a result of destruction
Lichenification
  • Thickening of the skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin
  • Leathery appearance

Special skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin lesions

  • Comedones: dilated hair follicles with debris such as keratin, sebum and, bacteria Bacteria Bacteria are prokaryotic single-celled microorganisms that are metabolically active and divide by binary fission. Some of these organisms play a significant role in the pathogenesis of diseases. Bacteriology: Overview (blackhead)
  • Burrows: a tunnel noted by raised lines, suggesting scabies Scabies Scabies is an infestation of the skin by the Sarcoptes scabiei mite, which presents most commonly with intense pruritus, characteristic linear burrows, and erythematous papules, particularly in the interdigital folds and the flexor aspects of the wrists. Scabies infection
  • Alopecia Alopecia Alopecia is the loss of hair in areas anywhere on the body where hair normally grows. Alopecia may be defined as scarring or non-scarring, localized or diffuse, congenital or acquired, reversible or permanent, or confined to the scalp or universal; however, alopecia is usually classified using the 1st 3 factors. Alopecia: hair loss
  • Telangiectasia: small, superficial blood vessels
  • Petechia: bruise < 3 mm
  • Purpura: bruise between 3 mm and 10 mm
  • Ecchymosis: bruise > 1 cm

Clinical Examination

Initial steps

  • Obtain informed consent:
    • Explain the need for the examination 
    • Describe the steps of the examination 
    • Ensure that the individual has a good understanding of the exam and agrees to proceed
  • Ask the individual to undress to their undergarments; have a chaperone present.

Components

  • Examination of skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin and mucosal surfaces:
    • Inspect
    • Palpate
    • Special tests
  • Examination of hair:
    • Inspection
    • Hair-pull test
  • Examination of nails: 
    • Inspection
    • Palpation

Examination of Skin and Mucosal Surfaces

All cutaneous and mucosal surfaces should be examined in good light. Wear gloves, especially if the skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin is broken.

Inspection

  • Appearance:
    • Site of lesion 
    • Number of lesions
    • Size of lesion 
    • Configuration
      • Linear 
      • Annular (circular with central clearing)
      • Grouped 
    • Morphology
      • Macular 
      • Papular 
      • Maculopapular 
      • Vesicular 
    • Color
    • Presence of scale or crust
  • Distribution:
    • Diffuse or localized
    • Symmetrical or asymmetrical
    • Dermatomal
    • Clustered or grouped
    • Mucosal involvement
    • Atypical sites (e.g., palms and soles)

Palpation

  • Lesional:
    • Tenderness 
    • Warmth 
    • Consistency
      • Hard 
      • Firm 
      • Fluctuant 
    • Raised
    • Flat
    • Texture changes
    • Induration
    • Blanching with pressure
  • Regional lymph node examination

Examination of mucosal surfaces

  • Oral cavity: buccal surface, palate Palate The palate is the structure that forms the roof of the mouth and floor of the nasal cavity. This structure is divided into soft and hard palates. Oral Cavity: Palate, and tongue Tongue The tongue, on the other hand, is a complex muscular structure that permits tasting and facilitates the process of mastication and communication. The blood supply of the tongue originates from the external carotid artery, and the innervation is through cranial nerves. Oral Cavity: Lips and Tongue 
  • Conjunctiva 
  • If sexually history is positive, examine the genital system.

Special tests

  • Nikolsky sign: 
    • Performed by rubbing across the surface of the skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin
    • If positive, the top thin layer of the skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin shears off, leaving tender, pink  skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin.
    • Positive sign indicates a blistering condition (e.g., pemphigus vulgaris Pemphigus vulgaris Bullous pemphigoid and pemphigus vulgaris are two different blistering autoimmune diseases. In pemphigus vulgaris, autoantibodies attack the desmosomal proteins, which connect the keratinocytes to one another. This attack results in a more severe, potentially fatal condition with fragile, flaccid blisters, usually with significant mucosal involvement. Bullous Pemphigoid and Pemphigus Vulgaris).
  • Dermographism: 
    • Involves stroking the surface of the skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin, resulting in hives Hives Urticaria is raised, well-circumscribed areas (wheals) of edema (swelling) and erythema (redness) involving the dermis and epidermis with associated pruritus (itch). Urticaria is not a single disease but rather is a reaction pattern representing cutaneous mast cell degranulation. Urticaria (Hives)
    • Often positive in conditions such as urticaria Urticaria Urticaria is raised, well-circumscribed areas (wheals) of edema (swelling) and erythema (redness) involving the dermis and epidermis with associated pruritus (itch). Urticaria is not a single disease but rather is a reaction pattern representing cutaneous mast cell degranulation. Urticaria (Hives)

Examination of Hair

Evaluate the hair carefully, looking for any changes from the individual’s baseline.

  • Texture
  • Color 
  • Quantity 
  • Distribution
  • Patches/ skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin lesions of the scalp
  • Hair loss 
    • Diffuse 
    • Patchy 
    • Pattern thinning 
  • Hair-pull test
    • Done to demonstrate the severity of hair loss 
    • Grasp around 60 hair strands, gently tug; > 3–5 hair strands coming out indicates active hair loss.
Table: Common hair loss conditions
Disease Description
Alopecia Alopecia Alopecia is the loss of hair in areas anywhere on the body where hair normally grows. Alopecia may be defined as scarring or non-scarring, localized or diffuse, congenital or acquired, reversible or permanent, or confined to the scalp or universal; however, alopecia is usually classified using the 1st 3 factors. Alopecia areata
  • Autoimmune disorder that affects both males and females
  • Circular areas of total hair loss
Androgenetic alopecia
  • Male or female pattern baldness
  • Due to a combination of genetic and hormonal factors
Telogen effluvium
  • Temporary hair loss due to excessive shedding of resting hairs after acute stressful events
  • Nonscarring form of diffuse hair loss

Examination of Nails

Inspect and palpate the nails carefully, looking for any changes.

  • Discoloration 
  • Symmetry 
  • Abnormal shape 
  • Abnormalities in the nail plate surface 
  • Complete loss of nails
  • Separation of the distal nail (onycholysis) 
  • Lesions around nails
Table: Common nail findings
Clinical findings Description Possible underlying etiology
Clubbing Loss of angle between the nail fold and nail plate
  • Cardiac: chronic heart failure
  • Inflammatory bowel disease
  • Liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver diseases
  • Pulmonary fibrosis Pulmonary Fibrosis Idiopathic pulmonary fibrosis is a specific entity of the major idiopathic interstitial pneumonia classification of interstitial lung diseases. As implied by the name, the exact causes are poorly understood. Patients often present in the moderate to advanced stage with progressive dyspnea and nonproductive cough. Pulmonary Fibrosis
Onycholysis Distal nail separation
  • Psoriasis
  • Fungal infection
  • Trauma
Nail pitting
  • Psoriasis
  • Eczema
Koilonychia Spoon-shaped depression Iron deficiency anemia Iron Deficiency Anemia Iron deficiency anemia is the most common type of anemia worldwide. This form of anemia is caused by insufficient iron due to a decreased supply, an increased loss, or an increased demand. Iron deficiency anemia is seen across all ages, sexes, and socioeconomic strata; however, children, women of childbearing age, and patients from lower socioeconomic strata are at higher risk. Iron Deficiency Anemia
Mees lines White streaks
  • Heavy- metal poisoning Metal poisoning Heavy metals poisoning is the toxic accumulation of metals in the body, which can occur due to ingestion or inhalation. These elements are normally found in nature and can have many applications; however, toxicity is rare. Common metals that the human body absorbs in toxic amounts are lead, arsenic, and iron. Metal Poisoning (Lead, Arsenic, Iron)
  • Renal failure
  • Chemotherapy
Brittle nails Hypothyroidism Hypothyroidism Hypothyroidism is a condition characterized by a deficiency of thyroid hormones. Iodine deficiency is the most common cause worldwide, but Hashimoto's disease (autoimmune thyroiditis) is the leading cause in non-iodine-deficient regions. Hypothyroidism
Yellow nail syndrome
  • Lung disease
  • Rheumatoid arthritis Rheumatoid arthritis Rheumatoid arthritis (RA) is a symmetric, inflammatory polyarthritis and chronic, progressive, autoimmune disorder. Presentation occurs most commonly in middle-aged women with joint swelling, pain, and morning stiffness (often in the hands). Rheumatoid Arthritis
Terry nails Proximal red/brown band on the nail plate
  • Congestive heart failure Congestive heart failure Congestive heart failure refers to the inability of the heart to supply the body with normal cardiac output to meet metabolic needs. Echocardiography can confirm the diagnosis and give information about the ejection fraction. Congestive Heart Failure
  • Liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver disease
Half-and-half nails Kidney disease
Muehrcke lines Double white lines Hypoalbuminemia

Clinical Relevance

Table: Common dermatologic conditions
Psoriasis Atopic dermatitis Acne vulgaris Acne vulgaris Acne vulgaris, also known as acne, is a common disorder of the pilosebaceous units in adolescents and young adults. The condition occurs due to follicular hyperkeratinization, excess sebum production, follicular colonization by Cutibacterium acnes, and inflammation. Acne Vulgaris Fungal infections
Appearance
  • Salmon-colored plaques
  • Thick, silvery scales
  • Pruritic
  • Lichenified (thickening of skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin)
  • Pink scaly plaques
  • Intensely pruritic
  • Comedones
  • Pustule
  • Nodules
  • Pruritic
  • Erythematous plaques
  • Leading edge of scale
Distribution Symmetrical, extensor surfaces Flexor surfaces Face, neck, chest, and back
  • Feet: interdigital (tinea pedis)
  • Trunk and extremities (tinea corporis (ringworm))
  • Groin (tinea cruris)
  • Scalp (tinea capitis)
Associated findings Auspitz sign: pinpoint bleeding with removal of scale History of atopy ( asthma Asthma Asthma is a chronic inflammatory respiratory condition characterized by bronchial hyperresponsiveness and airflow obstruction. The disease is believed to result from the complex interaction of host and environmental factors that increase disease predisposition, with inflammation causing symptoms and structural changes. Patients typically present with wheezing, cough, and dyspnea. Asthma and seasonal allergies) Scarring/hyperpigmentation Confirmed by KOH prep

References

  1. Cole, J.M., Gray-Miceli, D. (2002). Necessary elements of a dermatologic history and physical evaluation. Dermatology Nursing. 14(6). Retrieved October 23, 2021, from https://www.medscape.com/viewarticle/447729
  2. DermNet NZ. (2008). Principles of dermatological practice—examination of the skin. Retrieved October 23, 2021, from https://www.dermnetnz.org/cme/principles/examination-of-the-skin/
  3. Armstrong, C.A. (2021). Approach to the clinical dermatologic diagnosis. UpToDate. Retrieved October 23, 2021, from https://www.uptodate.com/contents/approach-to-the-clinical-dermatologic-diagnosis
  4. Stanford Medicine. (n.a.) The hand examination. Retrieved October 23, 2021, from https://stanfordmedicine25.stanford.edu/the25/hand.html

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