Evaluation of Skin Disorders




Abstract


Dermatology is best approached by classifying cutaneous and oral disorders by the primary lesion (e.g., macule, tumor) and the distribution of lesions (e.g., facial, axillary, and oral). Primary lesions are the initial lesion that has not been altered by trauma, secondary lesions (e.g., excoriation), or natural regression. This introductory chapter organizes mucocutaneous disorders by their primary lesion and distribution to aid in the development of broad differential diagnosis.




Key words

Macule, papule, plaque, nodule, alopecia, pustule, tumor, vesicle, bulla, erosion, ulcer, desquamation

 





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.



    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?




    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









Dermatoses by Anatomic Region



Scalp


Papules/Plaques





  • Actinic keratosis



  • Appendageal tumor



  • Cyst



  • Hemangioma



  • Lichen planopilaris



  • Lupus erythematosus



  • Melanoma



  • Nevus



  • Seborrheic keratosis



Nodules





  • Actinic keratosis



  • Appendageal tumor



  • Basal cell carcinoma



  • Cyst



  • Hemangioma



  • Kerion



  • Metastatic carcinoma



  • Nevus



  • Prurigo nodularis



  • Seborrheic keratosis



Eruptions





  • Contact dermatitis



  • Dissecting cellulitis



  • Eczema



  • Folliculitis



  • Herpes zoster



  • Pediculosis capitis



  • Psoriasis



  • Seborrheic dermatitis



  • Tinea capitis



Alopecias





  • Alopecia areata



  • Anagen effluvium



  • Androgenetic alopecia



  • Discoid lupus erythematosus



  • Hypervitaminosis A



  • Lichen planopilaris



  • Syphilis



  • Systemic disease



  • Telogen effluvium



  • Tinea capitis



  • Traction/chemical alopecia



  • Trichotillomania




Face


Isolated Papules





  • Acrochordon



  • Actinic keratosis



  • Angioma



  • Appendageal tumors



  • Basal cell carcinoma



  • Cyst



  • Dermatosis papulosa nigra



  • Hemangioma



  • Keratoacanthoma



  • Lentigo maligna



  • Milia



  • Nevus



  • Sebaceous hyperplasia



  • Seborrheic keratosis



  • Solar lentigo



  • Squamous cell carcinoma



  • Telangiectasia



  • Venous lake



  • Xanthelasma



Eruptions





  • Acne rosacea



  • Acne vulgaris



  • Angiofibroma (Adenoma sebaceum)



  • Dermatomyositis



  • Eczema, including contact dermatitis



  • Erysipelas



  • Favre-Racouchot (comedones in actinically damaged skin)



  • Fifth disease



  • Herpes simplex/zoster



  • Impetigo



  • Lupus erythematosus



  • Lymphocytoma cutis



  • Melasma



  • Pemphigoid/pemphigus



  • Perioral dermatitis



  • Photodrug eruption



  • Pityriasis alba



  • Postinflammatory hypopigmentation



  • Psoriasis



  • Sarcoidosis



  • Scleroderma



  • Seborrheic dermatitis



  • Steroid rosacea



  • Syphilis



  • Tinea corporis



  • Urticaria, angioedema



  • Warts, especially flat or molluscum




Oral Mucosa


Oral Mucosa (See also “Erosions and Ulcers”)





  • Kaposi’s sarcoma



  • Leukoplakia



  • Melanoma



  • Mucous cysts



  • Oral hairy leukoplakia



  • Oral melanotic macule



  • Pyogenic granuloma



  • Verruca




Axilla





  • Acanthosis nigricans



  • Acrochordon



  • Axillary freckling in neurofibromatosis



  • Bullous pemphigoid



  • Contact dermatitis



  • Epidermal inclusion cyst



  • Erythrasma



  • Fox-Fordyce disease



  • Fungal or yeast infection



  • Hailey-Hailey disease



  • Hidradenitis suppurativa



  • Intertrigo



  • Pediculosis corporis



  • Pseudoxanthoma elasticum



  • Scabies



  • Striae distensae



  • Trichomycosis axillaris




Hands and Feet


Isolated Papules





  • Actinic keratosis



  • Arsenical keratosis



  • Basal cell carcinoma



  • Callus/clavus



  • Felon



  • Keratoacanthoma



  • Melanoma



  • Nevus



  • Painful fat herniations



  • Pyogenic granuloma



  • Solar lentigo



  • Squamous cell carcinoma



  • Warts



Eruptions





  • Acute or chronic paronychia



  • Cutaneous larva migrans (feet)



  • Dermatomyositis



  • Drug eruption



  • Eczema, including contact dermatitis



  • Emboli



  • Epidermolysis bullosa



  • Erythema multiforme



  • Granuloma annulare



  • Hand-foot-and-mouth disease



  • Herpetic whitlow



  • Hyperhidrosis



  • Juvenile plantar dermatosis



  • Keratolysis exfoliativa



  • Lichen planus (wrists, ankles)



  • Lupus erythematosus



  • Pitted keratolysis (feet)



  • Pityriasis rubra pilaris



  • Porphyria cutanea tarda



  • Psoriasis



  • Reiter’s syndrome



  • Rocky Mountain spotted fever



  • Scabies



  • Scleroderma



  • Syphilis



  • Tinea pedis, manus



  • Viral exanthems



  • Vitiligo




Genitalia/Inguinal





  • Acrochrodons



  • Accrodermatitis enteropathica



  • Angiokeratoma



  • Balanitis



  • Bowen’s disease



  • Candidiasis



  • Chancroid



  • Condyloma accuminata



  • Contact dermatitis



  • Diaper dermatitis



  • Erythema multiforme



  • Erythrasma



  • Fixed drug eruption



  • Folliculitits



  • Furunculosis



  • Herpes simplex/zoster



  • Hidradenitis suppurativa



  • Intertrigo



  • Kawasaki syndrome



  • Lichen planus



  • Lichen sclerosus



  • Lichen simplex chronicus



  • Lymphogranuloma venereum



  • Molluscum contagiosum



  • Paget’s disease, extramammary



  • Pearly penile papules



  • Pediculosis pubis



  • Perianal streptococcal cellulitis



  • Pinworm



  • Pityriasis rubra pilaris



  • Psoriasis



  • Reiter’s syndrome (reactive arthritis)



  • Scabies



  • Seborrheic dermatitis



  • Squamous cell carcinoma



  • Syphilis



  • Tinea cruris




Photodistributed





  • Dermatomyositis



  • Lupus erythematosus



  • Pellagra



  • Photodrug eruption



  • Polymorphous light eruption



  • Porphyria cutanea tarda


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Sep 22, 2019 | Posted by in Dermatology | Comments Off on Evaluation of Skin Disorders
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