Introduction

Dermatology became a distinct medical subspecialty at the end of the 18th century; however, many dermatologic disorders were first described more than 2000 years ago. When confronted with a dermatologic complaint, you may recall the old adage, “If it’s wet, dry it, and if it’s dry, wet it.” This treatment approach has been ascribed to Hippocrates. During the third century BC, his Hippocratic Collection, also known as the Corpus Hippocraticum, described the anatomy and physiology of the skin and various cutaneous manifestations of systemic disease. He noted, for instance, that clubbed nails are associated with underlying pulmonary disease and that urticaria is associated with swollen joints. ^, Hippocrates exerted that physicians should do the opposite to the body of what was inflicted by the disease, such as applying a drying agent to a moist area and applying emollients to a dry area.

Today dermatology is a highly sought after medical specialty, attracting the best and brightest medical students to 4-year residency programs across the United States. A varied specialty that requires knowledge of internal medicine, dermatopathology, microbiology, clinical dermatology, surgical care, oncology, cosmetic care, laser treatment, allergic care, rheumatology, and preventive medicine, dermatology is a growing specialty area for physician assistants (PAs). According to the 2016 National Commission on Certification of Physician Assistants (NCCPA) profile report, 3.9% of PAs identify themselves as dermatology PAs. The growth of PAs in dermatology is important because the number of dermatology residency and fellowship positions for medical school graduates is lower than in many other specialties, and the number of retiring dermatologists will continue to rise over the next decade, contributing to a dermatology provider shortage. PAs have become integral to many dermatology practices. Data from 2014 show that the majority of dermatology group practices now employ physician extenders. Dermatology PAs are addressing the dermatology shortage by increasing the average U.S. dermatology provider density to meet the goal of 4 dermatology providers for every 100,000 people.

Approach to the patient

The skin is the largest and most visible organ system, which can be both an advantage and disadvantage for providers. On one hand, the pathology is often readily visible to the naked eye; on the other, a student may be overwhelmed by the variety of normal variants in the skin and miss key or subtle signs of skin disease. When approaching a dermatologic patient, examine the patient after a brief patient interview but before taking a detailed history. Many cutaneous lesions are so characteristic that the diagnosis will announce itself during the physical examination. Often the patient will present a history that is inconsistent with the diagnosis or related to his or her own interpretation of the origin of the lesion, which may mislead the provider assessing the patient. A quick visual inspection before detailed questioning will lead the provider down one of two paths: (1) biopsy to establish a diagnosis, or (2) diagnosis and treatment.

When conducting a skin examination, it is essential to perform a complete examination during the visit. The ideal examination includes evaluation of the skin, hair, and nails, as well as the mucous membranes of the mouth, eyes, nose, nasopharynx, and anogenital region. Patients often present with complaints concerning a single lesion that is worrisome to them, which are actually benign. Many patients have never had a skin cancer screening examination and are focused on the initial complaint, not knowing they have other, more concerning lesions. A baseline skin cancer screening examination allows for the documentation of changes from the original skin exam, establishing a timeline for concerning skin changes. After the visual inspection is complete, then a more thorough history of present illness and review of systems should be conducted. The history of present illness should document:

• 1.
  

  History or evolution of the skin lesion: when (onset), where (site of onset), symptoms (pain/itch), how it spread (pattern or evolution of spread), how the individual lesions have changed, provocative factors (heat, cold, sun, exercise, travel, drug ingestion, pregnancy, season), and previous treatment (topical or systemic, over-the-counter or home remedies)

  
  
• 2.
  

  Constitutional symptoms: acute illness symptoms, such as headache, fever, chills, weakness, or joint pain, versus chronic illness symptoms, such as fatigue, weakness, anorexia, weight loss, and malaise

  
  
• 3.
  

  Recent exacerbation of chronic illness

  
  
• 4.
  

  Past medical history: operations, illnesses, allergies, medications, habits (smoking, alcohol or drug use), and atopic history (asthma, hay fever, eczema).

  
  
• 5.
  

  Family medical history: of particular importance are history of psoriasis, atopy, melanoma, xanthomas, and tuberous sclerosis

  
  
• 6.
  

  Social history, particularly occupation, hobbies, exposures, and travel

  
  
• 7.
  

  Sexual history: history of human immunodeficiency virus (HIV) risk factors, blood transfusions, intravenous drug use, and sexual activity

After the physical examination and history are complete, the dermatology provider will develop a differential diagnosis and formulate a treatment plan. Biopsy results often confirm the final diagnosis.

PA students will find that dermatology providers are very specific in their documentation of skin changes and lesions. The student should be able to apply the MAD approach for describing skin lesions: M for morphology, A for arrangement, and D for distribution. Morphology includes the type, size, shape, color, elevation, and margination of the lesion(s). When describing the type of lesion, the student should be aware that there are primary and secondary changes in the skin ( Table 29.1 and Fig. 29.1 ). The arrangement of lesions may be single, grouped, arciform, annular, serpiginous, and so on ( Table 29.2 ). The distribution of lesions may be localized, disseminated, or in other recognized patterns, which should always be assessed and documented. The distribution of lesions often predicts diagnosis ( Fig. 29.2 ). By being observant and specific in the description of the lesions, the examiner will often make the diagnosis without further unnecessary testing. Many skin diseases have pathognomonic descriptions. For instance, when reviewing medical documentation, “grouped papules or vesicles on an erythematous base” is clearly herpes to any trained medical provider.

Primary lesions.

(From Longo DL, Fauci AS, Kasper DL, et al. Harrison’s Principles of Internal Medicine , 18th ed. New York: McGraw-Hill; 2012. http://www.accessmedicine.com.easyaccess2.lib.cuhk.edu.hk . Copyright The McGraw-Hill Companies, Inc. All rights reserved.)

Table 29.2

Arrangement, Distribution, and Other Identifying Skin Lesion Terms

Arrangement	Grouped or disseminated; grouped lesions are further defined as herpetiform (grouped vesicles), arciform (partial ring or bow shaped), annular (round), reticulated (net shaped), linear (straight line), or serpiginous (snakelike)
Distribution	Isolated single lesion or localized to one body area; localized to one regional area; generalized; or universal
OTHER DESCRIPTORS
Palpation	Consistency: soft, firm, hard, fluctuant or nonfluctuant, or sandpaper
Temperature	Warm, hot, or cold
Mobility	Mobile (freely movable) or nonmobile
Tenderness	Tender or nontender
Number	Single or multiple; disseminated lesions are further defined as scattered discrete lesions
Lichenification	Thickened skin with distinct borders
Macerated	Swollen and softened by an increase in water content
Confluence	Confluent or nonconfluent
Pattern	Symmetric, sun-exposed, sites of pressure, intertriginous areas, follicular, random or following Blaschko skin lines

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