Dermatologic Examination

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. Skin: Structure and Functions.

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. Skin: Structure and Functions lesions

• Comedones Comedones Acne Vulgaris: dilated hair follicles with debris such as keratin Keratin A class of fibrous proteins or scleroproteins that represents the principal constituent of epidermis; hair; nails; horny tissues, and the organic matrix of tooth enamel. Two major conformational groups have been characterized, alpha-keratin, whose peptide backbone forms a coiled-coil alpha helical structure consisting of type I keratin and a type II keratin, and beta-keratin, whose backbone forms a zigzag or pleated sheet structure. Alpha-keratins have been classified into at least 20 subtypes. In addition multiple isoforms of subtypes have been found which may be due to gene duplication. Seborrheic Keratosis, sebum Sebum The oily substance secreted by sebaceous glands. It is composed of keratin, fat, and cellular debris. Infectious Folliculitis 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 (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 Telangiectasia Permanent dilation of preexisting blood vessels creating small focal red lesions, most commonly in the skin or mucous membranes. It is characterized by the prominence of skin blood vessels, such as vascular spiders. Chronic Venous Insufficiency: small, superficial blood vessels
• Petechia: bruise < 3 mm
• Purpura: bruise between 3 mm and 10 mm
• Ecchymosis Ecchymosis Extravasation of blood into the skin, resulting in a nonelevated, rounded or irregular, blue or purplish patch, larger than a petechia. Orbital Fractures: bruise > 1 cm

Clinical Examination

Initial steps

• Obtain informed consent Informed consent Informed consent is a medicolegal term describing the documented conversation between a patient and their physician wherein the physician discloses all relevant and necessary information to a patient who is competent to make an informed and voluntary decision regarding their care. Competency, disclosure, and voluntariness are the key elements upon which IC is based. 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. Skin: Structure and Functions 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. Skin: Structure and Functions 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 Crust Dried exudate of body fluids (blood, pus, or sebum) on an area of damaged skin Secondary Skin Lesions
• 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 Lymph The interstitial fluid that is in the lymphatic system. Secondary Lymphatic Organs 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. Palate: Anatomy, 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. Lips and Tongue: Anatomy 
• Conjunctiva Conjunctiva The mucous membrane that covers the posterior surface of the eyelids and the anterior pericorneal surface of the eyeball. Eye: Anatomy 
• 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. Skin: Structure and Functions
  • 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. Skin: Structure and Functions 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. Skin: Structure and Functions.
  • 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. Skin: Structure and Functions, 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 Patches Vitiligo/ 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. Skin: Structure and Functions 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.

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 Onycholysis Separation of nail plate from the underlying nail bed. It can be a sign of skin disease, infection (such as onychomycosis) or tissue injury. Psoriasis) 
• Lesions around nails

Clinical Relevance