An initial assessment for patients with skin disorders should be approached as you would any patient. A comprehensive assessment of a dermatologic condition includes the history given by the patient (subjective data) and the findings of the physical examination of the integumentary system (objective data). The patient history and physical examination should also occur in an appropriately private area to ensure privacy and dignity, preferably with natural lighting. A preliminary history of a dermatologic problem can be abbreviated to three key questions, which evaluate onset and evolution, symptoms, and treatment to date (Box 2-1
Skin provides an opportunity for visual inspection. This makes inspection the most important part of the physical examination of the skin. Physical examinations should be done in an orderly manner to insure important diagnostic clues are not missed. The initial key impression of whether the patient appears ill or not is important to note at the beginning of the physical examination.
Lesions can be defined as primary or secondary. Primary lesions are structural changes in the skin that have specific, visual characteristics and develop without any preceding skin changes (Table 2-1
). Secondary lesion is one that has changed due to natural progression or due to physical factors such as rubbing or scratching (Table 2-2
). Special or “other” lesions are those that occur in the skin only and in the skin most often or can be perceived most easily on the skin (Table 2-3
Specific terminology is used to describe the characteristics of skin lesions (number, color, type of lesion, configuration, distribution pattern, which can then be documented). These descriptive clues aid in diagnosing and managing the patient by healthcare providers. It is important to use generally accepted descriptive terminology for verbal and written documentation to ensure continuity and to assist health care providers to interpret the findings. The general examination of the skin considers normal variants and general changes in the skin. A wide range of normal variations exist in the skin across the life span, which may be due to age, genetic factors, and environmental influences (Table 2-4
II. PATIENT HISTORY (SUBJECTIVE DATA)
The traditional approach to assessment in general is to take the history prior to performing a physical examination. However, in dermatology, some providers prefer to do this
is in a reverse order to expedite the process. A preliminary history helps to establish rapport and engages the patient in the process. Then, moving to physical examination allows appropriately chosen selective questions to be asked subsequently. The general history of current illness is ideally obtained by allowing patient to use their own words regarding his/her skin condition. This gives the provider a sense of direction as to which triage questions to ask. Initially, try to allow the patient to talk uninterrupted. This preliminary history can be abbreviated to three key questions, which evaluate onset and evolution, symptoms, and treatment to date (Box 2-1
). Answers to these questions provide a great deal of information about how the condition has started and evolved over time. Review of systems is indicated by the acute or chronic current condition. Symptoms often drive how far one will go in looking for an etiology. Treatment is so key as oftentimes, regardless
whether over-the-counter or prescription medications, it can be the very thing causing or contributing to the problem.
TABLE 2-1 Primary Skin Lesions and Commonly Occurring Dermatologic Conditions
Primary Skin Lesions Description
Example of Dermatologic Condition
Example of Dermatologic Condition
A circumscribed, flat discoloration, which varies widely in size, color, and shape
Café au lait spot
Fixed drug eruption
Photoallergic drug eruption
Phototoxic drug eruption
Tinea nigra palmaris
Maculae ceruleae (lice)
Juvenile rheumatoid arthritis
Idiopathic guttate hypomelanosis
A solid, elevated palpable lesion on the skin <1 cm. It is round and sometimes pointed, is usually red but can be white, yellow, brown, or black, and may be associated with secondary lesions like scale and crust.
Flesh colored, yellow, or white
Basal cell epithelioma
Closed comedones (acne)
Lichen sclerosus et atrophicus
Pearly penile papules
Chondrodermatitis nodularis chronica helicis
Polymorphic light eruption
Blue or violaceous
A solid lesion that covers more than 1 cm of surface skin, which is often elevated or thickened and formed by closely clustered papules
Cutaneous T-cell lymphoma
Papulosquamous (papular and scaling) lesions
Discoid lupus erythematosus
A solid, elevated palpable mass that is usually larger than 0.5 cm. Sometimes considered a small tumor, nodules are located in the epidermis or extend deeper to the dermis or subcutaneous tissue.
Basal cell carcinoma
Sporotrichosis squamous cell carcinoma
Firm, edematous plaque resulting from infiltration of the dermis with fluid. Wheals are transient and a hypersensitivity response. Shape is often irregular. Sizes usually range from 3 mm to 12 cm.
Urticaria pigmentosa (mastocytosis)
A circumscribed elevated lesion containing whitish or yellowish elevations of the skin filled with purulent exudate, usually a collection of leukocytes and free fluid
A round, raised lesion containing clear or purulent fluid that is up to <1 cm. They are either sparsely scattered or specifically grouped.
This is a circumscribed collection of free fluid that is larger than 1 cm in diameter. It is mostly superficial in nature, and ruptures easily.
Bullous lichen planus
A primary lesion is a visually recognized structural change in the skin. It has specific characteristics and develops without any preceding skin change.
Adapted from Habif, T. P. (1996). Clinical dermatology: A color guide to diagnosis and therapy (3rd ed., pp. 3-11). St. Louis, MO: Mosby-Yearbook, Inc.
B. Information regarding other family members with similar symptoms, past medical history, previous and current drug therapy (including all over-the-counter preparations like herbs, vitamins, and natural supplements), occupation, and social history are all important parts of the initial interview.
1. Family history is important. Conditions such as psoriasis, eczema, skin cancer, or even keratosis pilaris have a genetic tendency. Patients may claim that another family member shares similar symptoms. For example, the diagnosis of atopic dermatitis is supported when the child presenting with chronic pruritic rash in antecubital fossa has a family history of atopic diseases (asthma, hay fever, and atopic dermatitis).
TABLE 2-2 Secondary Skin Lesions and Commonly Occurring Dermatologic Conditions
Secondary Skin Lesions Description
Commonly Occurring Dermatologic Conditions
Excess dead epidermal cells that are produced by abnormal keratinization and shedding
Fine to stratified
Lupus erythematosus (carpet tack)
Pityriasis rosea (collarette)
Scarlet fever (fine, on trunk)
Xerosis (dry skin)
Scaling in sheets
Scarlet fever (hands and feet)
Staphylococcal scalded skin syndrome
A collection of dried serum and cellular debris; a scab
Acute eczematous inflammation
Atopic dermatitis (face)
Impetigo (honey colored)
A focal loss of epidermis; erosions do not penetrate below the dermoepidermal junction and therefore heal without scarring.
Toxic epidermal necrolysis
A focal loss of epidermis and dermis; ulcers heal with scarring.
Necrobiosis lipoidica diabeticorum
A linear loss of epidermis and dermis with sharply defined, nearly vertical walls
Chapping (hands, feet)
A depression in the skin resulting from thinning of the epidermis or dermis
Discoid lupus erythematosus
Lichen sclerosus et atrophicus
Necrobiosis lipoidica diabeticorum
Topical and intralesional steroids overuse
An abnormal formation of connective tissue implying dermal damage; after injury or surgery, scars are initially thick and pink, but with time, scars become white and atrophic.
A secondary lesion is a lesion that has changed due to its natural evolution or due to physical change (scratching, irritation, or secondary infection).
TABLE 2-3 Special Lesions/Other
Hemorrhages from superficial blood vessels, <5 mm
Hemorrhages from superficial blood vessels, 5 mm to 5 cm
Bleeding into the tissue affecting large areas
Thickening of the skin with exaggerated markings due to prolonged rubbing or scratching
Dermal hypertrophy causing the skin to become thicker and firmer. The skin markings remain unchanged.
Circumscribed or diffuse hardening or induration of the skin resulting from dermal or subcutaneous edema, cellular infiltration, or collagen proliferation
Thickening and whitening of the horny cell layer caused by excessive moisture
A linear or “dug out” traumatized area, usually self-inflicted
A sac containing liquid or semisolid material
Deep form of folliculitis with pus accumulation
Localized accumulation of purulent material deep within the dermis
A characteristic linear lesion caused by tunneling in the stratum corneum produced by an animal parasite
Mass of keratin and sebum within the dilated orifice of a hair follicle
2. Medical history is significant, including illnesses—particularly chronic illness, which may manifest in the skin—and surgical procedures, for example, if the patient presents with diffuse hair loss or perhaps an unusual rash that may be due to an unresolved strep infection or recent infections occupied by high fever. In another scenario, a past history of chickenpox is helpful in evaluating the patient suspected with herpes zoster.
3. Medication history and medication allergy can take time to update in a comprehensive manner. Then for example, obtaining information regarding current prescription therapy or medicines recently used, including all topicals; systemic medications including steroids; vitamins, and dietary supplements complementary or over-the-counter medications; and home remedies. Drugs or medications can cause multiple types of skin conditions.
4. Occupational history is important in skin disease when patients have occupation-associated symptoms or those which improve over a weekend or resolve while on vacation. In conditions such as occupational contact dermatitis, significant short- and long-term disability, and legal issues may coexist.
TABLE 2-4 Normal Skin Findings and Variations Across the Life Span
Areas of Concern
Normal Adult Findings
Variations in Children
Variations in Older Adults
Color and tone
Deep to light brown in blacks; whitish pink to ruddy with olive or yellow overtones in whites.
Newborn reddish first 8 to 24 h and then pale pink with transparent tone; slight jaundice starting 2nd or 3rd day of life; mottled appearance of hands and feet in newborns disappears with warming; in black newborns, melanotic pigmentation not intense with exception of nail beds and scrotum
Skin of white persons tends to look paler and more opaque.
Sun-darkened areas; areas of lighter pigmentation in dark-skinned persons (palms, lips, nail beds); labile pigmentation areas associated with use of hormones or pregnancy; callused areas appear yellow; crinkled skin areas darker (knees and elbows); darkskinned (Mediterranean origin) persons may have lips with bluish hue; vascular flush areas (cheeks, neck, upper chest, or genital area) may appear red, especially with excitement or anxiety; skin color masked through use of cosmetics or tanning agents
Upper and lower extremities similar in color
More freckles; uneven tanning; pigment deposits; hypopigmented patches
Minimum perspiration or oiliness felt; dampness in skin folds; increased perspiration associated with warm environment of activity; wet palms, scalp, forehead, and axilla associated with anxiety
Perspiration present in all children over 1 mo of age
Increased dryness, especially of extremities; decreased perspiration
Cool to warm
Smooth, even, and soft; some roughness on exposed areas (elbows and soles of feet)
Smooth, soft, flexible, dryness, and flakiness of skin in infants <1 mo of age (shedding of vernix caseosa); may appear as white cheesy skin; presence of milia; small white papules over nose and cheeks (plugged sebaceous glands) may remain for 2 mo.
Flaking and scaling associated with dry skin, especially on lower extremities
Wide body variation; increased thickness in areas of pressure or rubbing (hands and feet)
Varying degrees of adipose tissue; dimpling of skin over joint areas
Thinner skin, especially over dorsal surface of hands and feet, forearms, lower legs, and bony prominences
Skin moves easily when lifted and returns to place immediately when released.
Skin moves easily when lifted but falls quickly when released; skin over extremities taut.
General loss of elasticity; skin moves easily when lifted but does not return to place immediately when released; skin appears lax; increased wrinkle pattern more marked in sun-exposed areas, in fair skin, and in expressive areas of face; pendulous parts sag or droop (under chin, earlobes, breasts, and scrotum).
Clean, free of odor
Striae (stretch marks) usually silver or pinkish; freckles (prominent in sun-exposed areas); some birthmarks
Café au lait spots (light, cream-colored spots on darkened background); some nevi; stork bites (small red or pink spots on back of neck, upper lip, or upper eyelid; usually disappear by 5 y of age)
Nevi often become lighter or disappear; seborrheic keratoses (pigmented raised, warty, slightly greasy lesions most often found on trunk or face); senile (actinic) keratoses on exposed surfaces; first seen as small reddened areas and then as raised, rough, yellow to brown lesions; senile sebaceous adenomas (yellowish flat papules with central depressions); cherry adenomas (tiny, bright, ruby red, round); may become brown with age
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