After studying this chapter, the reader will be able to:
Define a holistic and comprehensive patient skin assessment.
List subjective and objective data, which are necessary for a comprehensive assessment of the skin.
Express the appropriate terminology used for primary and secondary lesions.
Describe primary and secondary lesions of the skin and examples of dermatologic conditions exhibiting these features.
Determine how lesion location and distribution help indicate specific diagnoses.
Identify factors influencing professional relationship with patients and other health care professionals.
KEY POINTS
A comprehensive, holistic skin assessment includes the history given by the patient (subjective data) and the findings of the physical exam of the skin (objective data).
The preliminary patient history can be abbreviated to three key questions, which evaluate onset and evolution, symptoms, and treatment to date.
Physical examination of the skin needs to be done ensuring privacy and dignity while determining whether the lesions being evaluated are primary or secondary lesions, as well as the configuration and distribution of the lesions.
During the assessment, do not underestimate the significance of pruritus or the changes in the hair and nails.
Specific terminology is used to describe the characteristics of skin lesions (number, color, type of lesion, configuration, distribution pattern, which can then be documented).
Specific standardized terminology provides all care providers with a uniform description and understanding of the patient’s condition. This can be especially important in completing consults with specialized providers, electronic communication, and telehealth visits.
Documentation and communication with other health care professionals and disciplines at appropriate levels and according to identified standards are important to ensure continuity.
I. OVERVIEW
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)
A. 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.
Box 2-1. Sample Questions for Initial Assessment or Triage
Key questions with initial history of skin problem:
Onset and Evolution: How long has the lesion been present? Has it gotten better or worse?
Symptoms: Does it itch? Or how does this bother you?
Treatment to Date: Tell me all the things that you have used to try to treat this?
Additional questions:
What did it first look like?
Has it changed, grown, bled, itched, or failed to heal?
Have you been out of the country lately?
Does it come and go?
Have you recently started any changes in your daily medicines?
Have you recently started any new medicines?
Any history of similar symptoms for you in the past?
Do any family members have the same or similar symptoms?
Have you used or done anything that seems to make it better?
TABLE 2-1 Primary Skin Lesions and Commonly Occurring Dermatologic Conditions
Primary Skin Lesions Description
Example of Dermatologic Condition
Example of Dermatologic Condition
Macule
A circumscribed, flat discoloration, which varies widely in size, color, and shape
Brown
Becker nevus
Café au lait spot
Erythrasma
Fixed drug eruption
Freckle
Junction nevus
Lentigo
Lentigo maligna
Melasma
Photoallergic drug eruption
Phototoxic drug eruption
Stasis dermatitis
Tinea nigra palmaris
Blue
Ink (tattoo)
Maculae ceruleae (lice)
Mongolian spot
Ochronosis
Red
Drug eruptions
Juvenile rheumatoid arthritis
Still disease
Rheumatic fever
Secondary syphilis
Viral exanthems
Hypopigmented
Idiopathic guttate hypomelanosis
Nevus anemicus
Piebaldism
Postinflammatory psoriasis
Radiation dermatitis
Tinea versicolor
Tuberous sclerosis
Vitiligo
Papule
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
Adenoma sebaceum
Basal cell epithelioma
Closed comedones (acne)
Flat warts
Granuloma annulare
Lichen nitidus
Lichen sclerosus et atrophicus
Milium
Molluscum contagiosum
Nevi (dermal)
Neurofibroma
Pearly penile papules
Sebaceous hyperplasia
Skin tags
Syringoma
Brown
Dermatofibroma
Keratosis follicularis
Melanoma
Nevi
Seborrheic keratosis
Urticaria pigmentosa
Warts
Red
Acne vulgaris
Atopic dermatitis
Cholinergic urticaria
Chondrodermatitis nodularis chronica helicis
Eczema
Folliculitis
Insect bites
Keratosis pilaris
Leukocytoclastic vasculitis
Miliaria
Polymorphic light eruption
Psoriasis
Scabies
Urticaria
Blue or violaceous
Angiokeratoma
Blue nevus
Lichen planus
Lymphoma
Kaposi sarcoma
Melanoma
Mycosis fungoides
Venous lake
Plaque
A solid lesion that covers more than 1 cm of surface skin, which is often elevated or thickened and formed by closely clustered papules
Atopic dermatitis
Contact dermatitis
Cutaneous T-cell lymphoma
Papulosquamous (papular and scaling) lesions
Discoid lupus erythematosus
Lichen planus
Pityriasis rosea
Psoriasis
Seborrheic dermatitis
Syphilis (secondary)
Tinea corporis
Tinea versicolor
Nodule
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
Erythema nodosum
Furuncle
Hemangioma
Kaposi sarcoma
Keratoacanthoma
Lipoma
Lymphoma
Melanoma
Metastatic carcinoma
Mycosis fungoides
Neurofibromatosis
Prurigo nodularis
Sporotrichosis squamous cell carcinoma
Warts
Xanthoma
Wheal
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.
Angioedema
Dermatographism
Hives
Insect bites
Urticaria pigmentosa (mastocytosis)
Pustule
A circumscribed elevated lesion containing whitish or yellowish elevations of the skin filled with purulent exudate, usually a collection of leukocytes and free fluid
Acne vulgaris
Candidiasis
Dermatophyte infection
Dyshidrosis
Folliculitis
Gonococcemia
Hidradenitis suppurativa
Herpes simplex
Herpes zoster
Impetigo
Psoriasis
Pyoderma gangrenosum
Rosacea
Varicella
Vesicle
A round, raised lesion containing clear or purulent fluid that is up to <1 cm. They are either sparsely scattered or specifically grouped.
Herpes simplex
Herpes zoster
Contact dermatitis
Dyshidrosis
Impetigo
Chickenpox
Bulla
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 pemphigoid
Pemphigus vulgaris
Bullous impetigo
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
Scales
Excess dead epidermal cells that are produced by abnormal keratinization and shedding
Fine to stratified
Erythema craquele
Ichthyosis (quadrangular)
Lupus erythematosus (carpet tack)
Pityriasis rosea (collarette)
Psoriasis (silvery)
Scarlet fever (fine, on trunk)
Seborrheic dermatitis
Syphilis (secondary)
Tinea (dermatophytes)
Xerosis (dry skin)
Scaling in sheets
Scarlet fever (hands and feet)
Staphylococcal scalded skin syndrome
Crusts
A collection of dried serum and cellular debris; a scab
Acute eczematous inflammation
Atopic dermatitis (face)
Impetigo (honey colored)
Pemphigus foliaceus
Tinea capitis
Erosions
A focal loss of epidermis; erosions do not penetrate below the dermoepidermal junction and therefore heal without scarring.
Candidiasis
Dermatophyte infection
Eczematous diseases
Intertrigo
Petechiae
Senile skin
Toxic epidermal necrolysis
Vesiculobullous diseases
Ulcers
A focal loss of epidermis and dermis; ulcers heal with scarring.
Aphthae
Chancroid
Decubitus
Factitial
Ischemic
Necrobiosis lipoidica diabeticorum
Neoplasms
Pyoderma gangrenosum
Radiodermatitis
Syphilis (chancre)
Stasis ulcers
Fissure
A linear loss of epidermis and dermis with sharply defined, nearly vertical walls
Chapping (hands, feet)
Eczema (fingertip)
Intertrigo
Petechiae
Atrophy
A depression in the skin resulting from thinning of the epidermis or dermis
Aging
Dermatomyositis
Discoid lupus erythematosus
Lichen sclerosus et atrophicus
Morphea
Necrobiosis lipoidica diabeticorum
Radiodermatitis
Striae
Topical and intralesional steroids overuse
Scar
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.
Acne
Burns
Herpes zoster
Hidradenitis suppurativa
Porphyria
Varicella
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
Petechia
Hemorrhages from superficial blood vessels, <5 mm
Purpura
Hemorrhages from superficial blood vessels, 5 mm to 5 cm
Ecchymosis
Bleeding into the tissue affecting large areas
Lichenification
Thickening of the skin with exaggerated markings due to prolonged rubbing or scratching
Induration
Dermal hypertrophy causing the skin to become thicker and firmer. The skin markings remain unchanged.
Sclerosis
Circumscribed or diffuse hardening or induration of the skin resulting from dermal or subcutaneous edema, cellular infiltration, or collagen proliferation
Maceration
Thickening and whitening of the horny cell layer caused by excessive moisture
Excoriation
A linear or “dug out” traumatized area, usually self-inflicted
Cyst
A sac containing liquid or semisolid material
Furuncle
Deep form of folliculitis with pus accumulation
Abscess
Localized accumulation of purulent material deep within the dermis
Burrow
A characteristic linear lesion caused by tunneling in the stratum corneum produced by an animal parasite
Comedo
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.
Uniformity
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
Moisture
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
Surface temperature
Cool to warm
Texture
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
Thickness
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
Turgor
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).
Hygiene
Clean, free of odor
Alterations
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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