Approach to a Dermatologic Patient (trans 1) partial Flashcards by Vin James Penalosa

REMEMBER
 It is acceptable to do the PE first, because the skin is very visible and sometimes, even without the history, just by looking at the skin lesion and location, you can make a good diagnosis but it does not mean that you should not perform good history taking.
 The diagnosis and treatment of dermatologic disease rests on the physician’s ability to recognize the basic (primary) and sequential (secondary) lesions of the skin
 If the patient is a good patient, he/she will consult on the 1st or 2nd day that the lesion will appear. However, most Filipinos come 1-2 weeks after, so the secondary lesion is the one that is usually observed, not the primary lesion.
 Skin lesions are visible and accessible.
 Physicians must learn how to “read” skin for clues to underlying systemic disease.

 The skin is a window to the inside, providing a clue on internal problems.
 The entire skin should be inspected in good light, preferably natural light or artificial light that resembles it. Correlate your findings with your observations in the mucous membranes. Diseases may manifest themselves in both areas and both are necessary for assessing the skin color.
 Dermatology is a “visual” specialty
 Advantage: since it is visible and accessible, and intervention such as biopsy can be performed easily and is non-invasive
 Disadvantage: there are thousands of diseases that for some, especially first timers, would look the same. Thus, one must be keen enough to distinguish.

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PHYSICAL EXAMINATION
Detailed examination of
o Skin
o Hair
o Nails
o Mucous membranes

Major characteristics of skin lesions
1. Color - function of 4 pigments
 Melanin (brownish hue)
 Oxyhemoglobin (erythematous hue)
 Deoxyhemoglobin (bluish hue)
 Carotene (yellowish hue)
**Children have a particularly yellowish color indicative of a diet high in mangoes, carrots, squash, and other yellow vegetable or fruits. This condition, called carotenemia, is not harmful (look at the palms, soles, and face).
2. Consistency and feel of lesion (elicited via palpation)
 Soft, doughy, firm, hard, “infiltrated”, moist, mobile, tender

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ABNORMALITIES IN SKIN COLOR

Brownish Skin Discoloration
Bronze, Dark, or Grayish Black Discoloration
Yellow Skin Discoloration
Hypopigmentation
Others

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ABNORMALITIES IN SKIN COLOR - Brownish Skin Discoloration

o Café-au-Lait Spots
 Due to increased melanin production
 A slightly but uniformly pigmented macule or patch with a somewhat irregular border, usually 0.5 to 1.5 cm in diameter; benign
 Only becomes significant if there are 6 or more of these spots, with a diameter of >1.5 cm. This suggests neurofibromatosis
o Addison’s Disease
 Hypofunction of the adrenal cortex
 Deposition of melanin is usually in the mucous membranes

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ABNORMALITIES IN SKIN COLOR - Bronze, Dark, or Grayish Black Discoloration

o Hemochromatosis
 Iron deposition in pancreas (e.g., Diabetes Mellitus)
 Skin bronzing and hyperpigmentation due to too much iron build up in the body

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ABNORMALITIES IN SKIN COLOR - Yellow Skin Discoloration

o Jaundice
 Can be caused by increased serum bilirubin due to RBC hemolysis → yellowish skin and sclera (most prominent discoloration).
 To differentiate icteric sclera from dirty sclera, it is important to have adequate lighting
o Carotenemia
 Unlike jaundice, it does not affect the sclera which remains white (caused by a diet high in carrots and other yellow vegetables or fruits)
 Not harmful, but indicates need for assessing dietary intake

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ABNORMALITIES IN SKIN COLOR - Hypopigmentation

o Vitiligo
 Acquired loss of melanin pigment
 Usually located in periorificial areas – perioral, periorbital, around the umbilicus and perianal
 Not scaly, as differentiated from tinea versicolor which is scaly
 Related to autoimmune disease such as Graveʼs Disease or Hashimotoʼs Thyroidits → order lab tests for TSH, T3, T4
 About 30% has hyperthyroidism → treat thyroid problem
o Tinea Versicolor
 Common superficial fungal infection
 Hypopigmentation with slightly scaly macules on the trunk neck and upper arms
 Not as white as vitiligo

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ABNORMALITIES IN SKIN COLOR - Others
o Anemia
 Yellow tinge – sallow appearance (unhealthy yellow or pale brown color)
 Best seen in areas where stratum corneum is thinnest (nails, lips, mucous membrane and palpebral conjunctiva)
 If patient has nail polish, ask her to remove it before examination to clearly see the true color of the nail.
o Erythema
 Increased cutaneous blood flow
 Most commonly a component of inflammation usually of 2 conditions:
1. Drug eruption
2 Viral exanthem – with fever, malaise, joint pains and lymphadenopathy such as in Rubella; usually not pruritic (unless Dengue)
**A good history should be obtained (2-4 weeks) to distinguish which one has occurred.

o Cyanosis
 Somewhat bluish color that is visible in toenails and toes which may be caused by impaired venous return.
 Two types:
1. Central cyanosis
- Best identified in the lips, oral mucosa, and tongue but may also be seen in the hands, nails, and feet
- Causes include advanced lung disease, congenital heart disease, abnormal hemoglobin
2. Peripheral cyanosis
- Hand, nails, and feet
- Causes include congestive heart failure, venous obstruction

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DISCOLORATION CAUSED BY DRUG INTAKE

Clofazimine
Quinacrine
Amiodarone
Minocycline

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DISCOLORATION CAUSED BY DRUG INTAKE - Clofazimine

 Dark Brown skin
 Treatment for leprosy
 Drug deposits the color on the lesion, making the lesions more prominent and noticeable.
 This means that the drug is taking effect because the drug is in the lesion.
 Explain to the patient that this discoloration is reversible.

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DISCOLORATION CAUSED BY DRUG INTAKE - Quinacrine

 Yellow skin (without eye involvement)

 Anti-arrhythmic

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DISCOLORATION CAUSED BY DRUG INTAKE - Amiodarone

 Bluish gray skin

 Anti-arrhythmic

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DISCOLORATION CAUSED BY DRUG INTAKE - Minocycline

 Bluish skin
 For severe acne (long-term therapy)
 Hyperpigmentation
 More common in Caucasians

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SKIN TURGOR
 Rapid assessment of tissue hydration especially in cases of diarrhea
 Lift a fold of skin and note the ease with which it lifts up (mobility) and speed with which it returns to place (turgor).
 Faster return means better hydration.
 Decreased turgor or delay in return in dehydration. (May also palpate axilla. – no perspiration if dehydrated)
 Decreased mobility in edema.

 Other skin characteristics:
o Moisture: dryness, sweating and oiliness
o Temperature: warmth or coolness of the skin
o Texture: roughness and smoothness
o Lesions

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HAIR
 Facial, axillary and pubic hairs are dependent on presence of sex hormones, thus, affected by sex and age of patient
 Excessive hair (especially women), maybe suggestive of an endocrine disease.
o PE and lab should aid in determining if it is due to an endocrine abnormality.

 Alopecia – refers to hair loss
 Sparse hair: indicative of hypothyroidism
 Fine silky hair: indicative of hyperthyroidism
 Intake of oral steroids: may cause hirsutism (abnormal hair growth in women)

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HAIR - Alopecia Areata
 Clearly demarcated round or oval patches of hair loss usually affecting young adults and children
 Commonly start as coin-shaped bald patches with 1 or 2 possible lesions
 Normally appears very clean (no visible scaling or inflammation) and a bit shiny
 If it appears dirty, suspect fungal infection of scalp.
 EXCLAMATION POINT HAIRS (stub-like) – pathognomonic of alopecia areata

Types:
 Localized
 Diffuse
 Generalized or Universal (severe type) – Scalp is not the only one affected, but also eyebrows, eyelashes, axillary, and pubic hair. Difficult to treat especially in children

HAIR - Anagen Effluvium

 Diminished hair shaft production due to marked inhibition of anagen (the first phase of the hair cycle, during which synthesis or growing of hair takes place)
 80% - 90% is in the anagen (growing) phase while 10% is only in the telogen (resting) phase
 Profound hair loss
 From patient undergoing chemotherapy or radiotherapy
o Usually manifest with total hair loss at 2nd cycle

HAIR - Telogen Effluvium

 Telogen is the resting state wherein the hair follicles do not produce any fiber
 Hormonal problem
 Shedding of hair seen in patients:
o with high grade fever
o with viral infection (Ex. Dengue Hemorrhagic Fever)
o 2-4 months after birth
 Doctor should assure patient that hair will be replaced and it is not caused by other causes like shampoo.
o Hair in the telogen phase pushed out to be replaced by the ones in the anagen phase (i.e. the shed hairs are typically telogen hairs)

HAIR - DLE-Scarring Alopecia

 Secondary systemic scarring alopecia in Discoid Lupus Erythematosus (DLE) – common form of chronic cutaneous lupus erythematosus
 reddish to purplish plaque, elevated and hyper keratinosis
 Usually occurs in females (2:1)
 Compared to Alopecia Areata:
o Surface of scalp is scarred
o Irreversible (no more hair growth in area)
 Focus of PE and biopsies: scalp and behind the ears to avoid false negative results

HAIR - Androgenetic Alopecia

 Poorest prognosis seen among males

 It is a genetic disease thus it is very difficult to treat and it also runs in the family

NAILS
 Provides a clue to certain systemic diseases
 Grows approx. 0.1mm daily; toenails grow more slowly
 Techniques of examination (Bates):
o Inspect and palpate the fingernails and toe nails
o Note their color and shape and any lesions
o Longitudinal bands of pigment may be seen in the nails of normal people who have normal skin

Psoriasis Vulgaris
Renal Disease
Hemochromatosis
Pulmonary, Hepatic, Cardiac, and GIT Conditions

NAILS - Psoriasis Vulgaris

Oil spots, loosening of nail, crumbling of nail, little pits on nails

 Onycholysis
o Painless separation of nail plate from nail bed
o Starts distally and progresses proximally, enlarging the free edge of the nail
 Nail Pitting
o Punctate depressions of the nail plate caused by defective layering of the superficial nail plate by the proximal nail matrix
o Look at the whole body of the patient specially the predilection for Psoriasis which is the scalp, elbows and the knees
o Look for silvery caseous scales which could indicate Psoriasis

NAILS - Renal Disease

 Half and Half Nails (“Lindsay’s Nails”)

o proximal white and distal pink (caucasians) or brown (Malay)

NAILS - Hemochromatosis

 Due to faulty iron metabolism
 Check serum iron levels and iron metabolism
 Koilonychia (spoon-shaped nails)
o abnormal thinness and concavity of fingernails

NAILS - Pulmonary, Hepatic, Cardiac, and GIT Conditions |  Cyanosis may be peripheral (e.g., venous obstruction and congenital heart failure) or central (eg., pulmonary edema)

 Clubbing o Clinically a bulbous swelling of the soft tissue at the nail base, with loss of normal angle between the nail and the proximal nail fold (the angle increases to ≥ 180°) o Nailbed feels spongy or floating o Involves vasodilatation with increased blood flow to the distal portion of the digits and changes in CT o Common in cardiac and congenital heart diseases (e.g.,Tetralogy of Fallot)

PHYSICAL EXAMINATION Four Cardinal Features: TSAD: Type, Shape, Arrangement, Distribution

1. Type of lesion 2. Shape and Arrangement of lesion 3. Distribution

PHYSICAL EXAMINATION - Type of lesion

 Primary or Secondary skin lesions o If possible, find representative and recent lesions that have not been traumatized by scratching or otherwise altered. o Inspect carefully and feel them.  Specify if macule, papule, nodule, vesicles, or nevi (moles)

PHYSICAL EXAMINATION - Shape and Arrangement of lesion  Provide clues to the diagnosis  The approach starts from looking at the big picture of the distribution from a distance → looking at the distribution of the lesions more closely → establishing the nature of individual lesions and their arrangement (Harrison’s)  May be linear, iris, annular (in a ring), arciform (in an arc), serpiginous (worm-like), round, oval, umbilicated

Shape and arrangement provides clues for diagnosis. 1. If it’s linear, and the patient is a gardener, then think of phytodermatitis. Linear shapes may be due to scratches from rose thorns. 2. If it’s annular or “bull’s eye” or iris lesion, consider erythema multiforme. May be due to infection or drug. 3. If there are vesicles in a band with one-sided dermatomal distribution, may be herpes zoster.

PHYSICAL EXAMINATION: | Shape and Arrangement of lesion - Linear

 Multiple, minute vesicular lesion in a linear arrangement  Starts from a flat red lesion -> becomes vesicular  From reaction to nuts, rust plants (i.e. poison Ivy, mango), leaf/sap; can cause phytodermatitis  Commonly seen in farmers, gardeners, and housewives  Usually found in exposed areas like the arms  Mango trees are the common culprit in the Philippines

PHYSICAL EXAMINATION: | Shape and Arrangement of lesion - Iris / Targe

 Pink to violatious “Bull’s eye” or iris lesions  Characteristic of Steven Johnson Syndrome/Erythema multiformes  90% most likely  Usually from drug-induced hypersensitivity  Usually manifested on extremities or palms and soles  Periphery: halo-like erythema  Middle: papule, vesicle, purpura, bullae or erythema

PHYSICAL EXAMINATION: | Shape and Arrangement of lesion - Herpetiform

 Grouped vesicles with erythematous base  Usually viral  Herpes simplex virus 1 (HSV1) - Grouped vesicles with erythematous base  Muco-cutaneous, asymmetric lesions - Vesicles arise and coalesce in mucocutaneous angle in the mouth  Herpes simplex 2 virus - Present in the genital area

PHYSICAL EXAMINATION: | Shape and Arrangement of lesion - Annular/Ring- like

Annular/Ring- like  Categorized as one of the granulomatous types of lesions  Ring-like lesion with a prominent border  May be seen in HIV patients  Also common in fungal infections (e.g., tineacapitis/tineacorporis)

PHYSICAL EXAMINATION: | Shape and Arrangement of lesion - Grouped Lesions

 Xanthomas (cholesterol deposits that can be yellowish or reddish in color) - Can occur in individuals with all subtypes of essential hyperlipidemia and secondary hyperlipedemia

PHYSICAL EXAMINATION: Shape and Arrangement of lesion - Zosteriform  Vesicles in a band on dermatome (dermatomal arrangement)  Commonly seen in those with reactivated chicken pox infection (e.g., shingles aka Herpes Zoster)  In elderly patients: grouped vesicles, extremely painful  If involves mucous membrane, think of a dermatologic emergency i.e. SJS (Stevens-Johnson Syndrome) due to drug hypersensitivity

Also found in Herpes zoster:  Erythematous lesion similar to herpes simplex reaction, but is asymmetric  50-70% found in trunk  Multiple coalescing vesicles

PHYSICAL EXAMINATION: Distribution  Extent of involvement: o Circumscribed, Regional, Generalized (entire body) or Universal (whole body surface)  Deals with the % of body surface involved o Rule of 9’s (Entire palm is roughly 1% of surface; the palm size of the patient is used in estimating the distribution) o If ≥ 30% involved: higher mortality rate  Pattern o Symmetry o Exposed areas, e.g. sun burn o Sites of pressure o Intertriginous areas, e.g. inframammary, axillary, inguinal areas. Where two opposing surfaces of the skin come in contact with each other mga singit singit

```  Characteristic location o Flexural, e.g. antecubital or popliteal area o Extensors, e.g. elbows and knees o Intertriginous o Glabrous (area devoid of hair) o Palms and soles o Dermatomal o Trunk o Lower extremities o Exposed areas  Questions to ask (Bates): o Are they localized or generalized? o Do they involve exposed surfaces, skin fold areas, flexor area, oracral (peripheral) areas? o Do they involve areas exposed to specific allergens or irritants? (e.g., wrist bands, rings, or industrial chemicals) ```