MED 1.1.2 Skin Assessment and Lesions

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1.1.2
02 June
2014

Assessment of the Skin and Lesions
Alfredo Guzman, MD
“The adrenaline and stress of an adventure are better than a thousand peaceful days.”
—Paulo Coelho
SKIN LESIONS― Paulo Coelho
COMPOSITION OF A USEFUL SKIN EXAMINATION
 Morphology (shape of the lesion)
 Configuration (arrangement of lesions)
 Distribution (Which body site)
TECHNIQUES OF EXAMINATION
* additional notes from Bates’ Guide to Physical Examination
and History Taking
1. Ensure that the patient wears a gown and is draped
accordingly to facilitate close inspection of the following:
• Hair
• Anterior and posterior surfaces of the body
• Palms and soles
• Web spaces between the fingers and toes
2. Inspect the entire skin surface in good light, preferably
natural light or artificial light that resembles it
• Artificial light often distorts colors and masks
jaundice.
3. Correlate your findings with observations of the mucuos
membranes, especially when assessing skin color, because
diseases may appear in both areas
SKIN
A. COLOR
1. Ask if patient observed a change in skin color.
• Increased pigmentation (browness)
• Loss of pigmentation
• Redness
• Pallow
• Cyanosis
• Yellowing of skin
2. Assess the red color of oxyhemoglobin and the pallor
in its absence where the horny layer of the epidermis
is thinnest and causes the least scatter.
• Fingernails, lips, mucous membranes of mouth
and palpebral conjunctiva
• In dark people – inspecting palms and soles may
also be useful
• CENTRAL CYANOSIS – best defined in the lips,
oral mucosa and tongue
3. Look for the yellow color of jaundice in sclera.
• May also be seen in palpebral conjunctiva, lips,
hard palate, undersurface of tongue, tympanic

MORPHOLOGICAL CLASSIFICATION OF LESIONS
 Primary Skin Lesions – unmodified lesions
 Secondary Skin Lesions – modified by scratching or infections
membrane, skin
• To see jaundice in the lips, blanch out the red
color by pressure of glass slide.
• Yellowness associated with high levels of
carotene (carotenemia), assess palms, soles,
and face.
B. MOISTURE – Dryness, sweating, and oiliness
C. TEMPERATURE
1. Use back of fingers to make general assessment.
2. Note the temperature in any red areas.
D. TEXTURE – roughness and smoothness
E. MOBILITY AND TURGOR
• Lift the skin and note the following:
o Ease with which it lifts up – Mobility
o Speed with which it returns into place – Turgor
F. LESIONS
EVALUATING BEDBOUND PATIENTS
• Assess patient by inspecting the skin that overlies the
scrotum, buttocks, greater trochanters, knees, and heels.
Pressure sores – caused by sustained compression that
obliterates arteriolar and capillary blood flow to the skin.
HAIR
Inspect and palpate hair. Note its quantity, distribution, and
texture.
NAILS
Inspect and palpate the fingernails and toenails. Note the
color, shape, and any lesions.
• Longitudinal bands of pigment – normal in people with
dark skin

I. PRIMARY SKIN LESIONS
GENERAL
CHARACTERISTIC
FLAT

CLASSIFIED AS

MACULE

PATCH
RAISED (SOLID)

PAPULE

NODULE

TUMOR

PLAQUE

TRANSCRIBED BY: LUKE, LEIA, HAN, CHEWBACCA

DESCRIPTION
 change in skin color
 up to 1 cm
 cannot be palpated





If macule is greater than 1 cm
solid raised lesion with distinct borders
less than 1 cm in diameter
may have a variety of shapes in profile (domed, flat-topped,
umbilicated)
 may be associated with secondary features: crusts or
scales
 a raised solid lesion more than 1 cm
 it may be in the epidermis, dermis, or subcutaneous tissue





a solid mass of the skin or subcutaneous tissue
larger than a nodule
not necessarily a neoplasm
a solid, raised, flat-topped lesion greater than 1 cm in
diameter.
 it is analogous to the geological formation, the plateau

EXAMPLE
 freckles, neurofibromatosis with
café au lait macules,
hypopigmented macules and
patch, vitiligo;
 hemangioma
 scabies, molluscum
contagiosum, Id reaction to
fungal infection,
papulosquamous lesions (buni)

 basal cell cancer, nodule in the
axilla (lymph node in cat scratch
fever)
 AV malformation, xanthomas

 tuberous sclerosis, psoriasis

Page 1 of 4

Skin and Lesions

RAISED (FILLED)

I. PRIMARY SKIN LESIONS
 raised lesions less than 1 cm in diameter that are filled
with clear fluid
 circumscribed fluid-filled lesions that are greater than 1
cm in diameter

VESICLES
BULLAE

 circumscribed elevated lesions that contain pus
 most commonly infected (as in folliculitis) but may be sterile
(as in pustular psoriasis)
 area of edema in the upper epidermis
 linear lesions produced by infestation of the skin and
formation of tunnels

PUSTULES
WHEAL
OTHERS
BURROWS

 permanent dilatation of superficial blood vessels in the
skin
 may occur as isolated phenomena or as part of a
generalized disorder, such as ataxia telangiectasia

TELANGIECTASIA

 hand, foot, and mouth disease
 Stevens-Johnsons Syndrome,
Contact dermatitis, severe
allergy
 group A beta-hemolytic
streptococcus infection
 urticaria (hives), insect bites
 with infestation by the scabitic
mite (galis aso) or by cutaneous
larva migrans
 spider or starburst
telangiectasia

II. SECONDARY SKIN LESIONS
CLASSIFICATION
1. SCALE

2. CRUST

3. ATROPHY

4. LICHENIFICATION

DESCRIPTION
 consists of flakes or plates that represent compacted
desquamated layers of stratum corneum.
 desquamation occurs when there are peeling sheets of scale
following acute injury to the skin.
 Exfoliation of epidermis
 result of the drying of plasma or exudate on the skin.
 Note: Please remember that crusting is different from scaling.
The two terms refer to different phenomena and are not
interchangeable. One can usually be distinguished from the
other by appearance alone.
 thinning or absence of the epidermis or subcutaneous fat
 (-) hair, sweat and oil due to lack of sebaceous and sweat glands
 refers to a thickening of the epidermis seen with exaggeration
of normal skin lines.
 It is usually due to chronic rubbing or scratching of an area.
 are slightly depressed areas of skin in which part or all of the
epidermis has been lost

5. EROSION

6. EXCORIATION

 are traumatized or abraded skin caused by scratching or
rubbing.
 linear cleavage of skin which extends into the dermis

7. FISSURE
8. ULCERATIONS

9. SCAR

10. ESCHAR

11. KELOIDS
12. PETECHIAE, PURPURA,
ECCHYMOSES (Bruise)

 occur when there is necrosis of the epidermis and dermis and
sometimes of the underlying subcutaneous tissue.
 Permanent fibrotic changes that occur on the skin following
damage to the dermis.
 Shiny, dry , thin
 a hard plaque covering an ulcer implying extensive tissue
necrosis, infarcts, deep burns, or gangrene
 look like very big ulcers
 an exaggerated connective tissue response of injured skin that
extend beyond the edges of the original wound.
 three terms that refer
to bleeding that
occurs in the skin
 easy bruising in
unlikely areas

PETECHIAE - smaller lesions
> DO NOT BLANCH
PURPURA & ECCHYMOSES- larger
lesions
> DO NOT BLANCH
HOW TO DIFFERENTIATE A
PALPABLE PURPURA FROM A
RASH:
press on the lesions carefully with a
glass slide; purpura do not blanch
when pressed

DISTRIBUTION

TRANSCRIBED BY: LUKE, LEIA, HAN, CHEWBACCA

III. DISTRIBUTION OF SKIN LESIONS
DESCRIPTION

EXAMPLE
 seborrheic dermatitis, tinea capitis
(poknat), Kawasaki disease
 cradle cap among infants – may
signify that infant is prone to allergy
and skin disease when he/she
grows up
 peri-oral lesions in impetigo (honey
colored adherent crust)

 linear areas of atrophy (striae)
secondary to chronic systemic
steroid administration; result of
advanced graft vs. host disease.
 pruritic scabies usually in the web
spaces between fingers
 tx: use anti-itch creams
 consequences of a self-inflicted
chemical burn, associated with
Stevens-Johnson syndrome
 in SJS all epidermal cells are
affected: GI and visceral cells, so px
is given antiulcer medications
 swimmer’s itch
 a fissure at the angle of lips as a
consequence of Kawasaki disease
 extensive ulceration of her lips after
having chewed on a live electrical
wire
 may have secondary pigment
characteristics
 meningococcemia
 keloid at the site of an old lymph
node biopsy site
 petechiae from thrombocytopenia
secondary to chemotherapy,
purpura associated with the disease
Henoch-Schönlein Purpura, suction
purpura caused by the medical
practice of cupping which has its
origins in antiquity, purpura and
ecchymosis on the skin as
presenting symptoms of acute
myelogenous leukemia

EXAMPLE

Page 2 of 4

Skin and Lesions

1. PHOTODISTRIBUTED
2. INTERTRIGINOUS

 on areas exposed to the sun
 on areas where skin rub each other; often wet and irritated
 along creases and fold
 along the path of lymph channels of leg or arm

3. LYMPHANGITIC
4. DERMATOMAL

5. PALMS AND SOLES

 area of skin following sensory innervations of a particular nerve
root
 does not cross midline of body
 Along palms and soles. You don’t say.
V. PATTERNS OF SKIN LESIONS
DESCRIPTION

PATTERNS
 seen in a ring shape
1. ANNULAR

2. DISCRETE

 tend to remain separate
 has little specific diagnostic significance
 are grouped together











face, neck, decolette, dorsal part of feet
axillary area
inguinal area
inframammary fold
leg and arm lymph path
fungal infection: sporotrichosos
T4 – along nipple line
C5- along shoulder
Herpes zoster

EXAMPLE
 Tinea corporis
 erythema migrans (the lesion associated with
lyme diseas
 granuloma annulare
 vesicles of varicella in a discrete pattern

 inflamed with a tendency toward clustering, oozing, or crusting

 commonly seen in herpes simplex or with insect
bites
 macular lesions of Kawasaki disease
 Dengue Hemorrhagic Fever
 The lesions of varicella zoster (also known as
shingles); other lesions may assume the same
pattern
 atopic dermatitis

 lesions that specifically involve the hair follicle

 keratosis pilaris

 look as though someone took a dropper and dropped this lesion
on the skin
 look like the “bull’s eye” in dartboards

 Guttate lesions are characteristic of one form of
psoriasis, though that is not the only example
 erythema multiforme
 Kawasaki disease
 lichen planus
 warts
 molluscum contagious
 psoriasis
 lichen nitidus
 systemic form of juvenile rheumatoid arthritis

3. CLUSTERED
 tend to run together
4. CONFLUENT
 follow a dermatome
5. DERMATOSOMAL
/ZOSTERIFORM
6. ECZEMATOID
7. FOLLICULAR
8. GUTTATE
9. IRIS OR TARGET
LESIONS
10. KOEBNER
PHENOMENON

11. LINEAR

12. MULTIFORM
13. RETICULAR

14. SERPIGINOUS

 also called the isomorphic response
 the appearance of lesions along a site of injury
o Auspitz sign
 tiny bleeding points (due to suprapapillary thinning) when
you remove a scale from psoriasis lesion
o Darier’s sign
 when you stroke lesion of urticaria
 pigmentosa (form of cutaneous mastocytosis)
 erythema & edema (due to mast cell degranulation with
histamine release)
o Nikolsky sign
 when you rub normal skin beside blister  induction of
new blister
 seen in pemphigus vulgaris and toxic epidermal
necrolysis(ten)
o Dermatographism
 when you stroke the normal skin  edema and erythema
(you can write on skin!)
 seen in physical urticaria
 occur in a line or band-like configuration.
 term may apply to a wide variety of disorders
 one should be certain that the lesions are not following a
dermatome
 lesions of a variety of shapes
 net-like lesions
 can be seen in a variety of circumstances

17. STRAWBERRY TONGUE





linear streaking associated with the lesion of
lichen striatus, poison ivy dermatitis
lymphangitis with linear streaking following
the line of the lymph system
erythema multiforme
very commonly in newborns (or even grown
children and adults) as cutis marmorata, or
with livedo reticularis. The former fades as
the skin is warmed the latter becomes more
florid
urticaria following a serpiginous route
alopecia universalis (patient with complete
absence of hair on his body, including the
absence of eyelashes and eyebrows)

 wander as though following the track of a snake
 refers to a widespread disorder that affects the entire skin




 have the pattern of scarlet fever
 the patient with a scarlatiniform rash has innumerable small red
papules that are widely and diffusely distributed
 note that the term scarlatiniform does not mean that the patient
has scarlet fever, although by definition all patients with scarlet
fever have a scarlatiniform rash.
 distinctive appearance in the tongue among patients with scarlet
fever, Kawasaki disease or other conditions
 because of its resemblance to the well-known berry, the
appearance is called "strawberry tongue."

 Kawasaki disease, viral infections, or drug
reactions

15. UNIVERSALIS

16. SCARLATINIFORM



TRANSCRIBED BY: LUKE, LEIA, HAN, CHEWBACCA

 scarlet fever
 Kawasaki disease

Page 3 of 4

Skin and Lesions

18. MORBILLIFORM

19. SATELLITE

20. PATTERNS OF
INTENTIONAL/UNINTENTIO
NAL INJURY

 since this eruption is on a mucus membrane, it is called an
enanthem
 a rash that looks like measles
 patients with measles will have the rash but patients with
Kawasaki disease, drug reactions, or other conditions may also
have a morbilliform rash.
 consists of macular lesions that are red and are usually 2-10
mm in diameter but may be confluent in places
 a portion of the rash of cutaneous candidiasis in which a beefy
red plaque may be found surrounded by numerous, smaller
red macules located adjacent to the body of the main lesions
 in cases of child abuse or other intentional injury (bite marks, slap
marks, strap marks, burns, etc.) or in cases of unintentional injury
 abrasions are traumatically caused erosions

 measles
 drug reaction to Dilantin

 candidal diaper dermatitis





rollerblading mishap
cigarette burn
linear ecchymosis from car crash
Battle sign: sign of basilar skull fracture;
bruising behind the ear

VI. COLOURS IN DERMATOLOGY
RED

Vascular lesions e.g. port wine stain; inflammatory disorders (psoriasis)

BLUE

Blue nevus; Mongolian spot

YELLOW

Xanthoma: deposition of yellow cholesterol rich material on tendons/ other body parts

WHITE

Vitiligo: Michael Jackson

BLACK

Melanocytic nevus ; melanoma

PURPLE/ VIOLACEOUS

Lichen planus

Configuration
Flat-topped

VII. CONFIGURATION
Disease
Lichen planus

Dome-shaped

Lymphomatoid
papulosis

Slightly elevated

Panniculus

Acuminate

Acute spongiotic
dermatitis

Papillated

Intradermal nevus

Digitated

Wart

Umbilicated

Molluscum
contagiosum

TRANSCRIBED BY: LUKE, LEIA, HAN, CHEWBACCA

Figure

Page 4 of 4

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