Derm Hx and Examination Flashcards
What questions should you ask in a hx of presenting complaint for a new skin lesion?
SOCRATES
Site - whereabouts is the lesion?
Onset - when did you first notice it? Any particular trigger? Had you been ill recently? Anything changed in your diet or skincare? Any new medications?
Character
Pain, itch, bleeding, discharge
Radiation - do you have similar lesions anywhere else?
Associated sxs - do systems review at the end
Time - has the lesion changed over time?
Exacerbating / Relieving
Severity - can you tell me about the impact that this is having on you?
What should you cover in a systems review for someone with a new skin lesion?
Systemic: fevers (e.g. cellulitis)
Cardiovascular: peripheral oedema
Respiratory: wheeze, dyspnoea (e.g. anaphylaxis)
Gastrointestinal: abdominal pain and diarrhoea (e.g. Crohn’s disease)
Neurological: confusion (e.g. meningococcal sepsis)
What triggers should you ask about for someone with a new skin lesion?
Any preceding illness? (before lesion appeared)
Any recent travel?
Any contact with people with similar lesions?
Any changes to your diet?
Any changes to your usual skincare/laundry detergent?
What conditions should you specifically ask about in the PMH of anyone with a new skin lesion?
Previous skin cancer/ skin conditions
Atopy / allergic reactions - what type of reaction do they have??
Diabetes
Inflammatory bowel disease (linked w pyoderma gangrenosum, erythema nodosum)
Conditions requiring systemic immunosuppression (HIV, transplant)
What should you ask in the family hx of someone presenting with a new skin lesion?
Any family hx of skin cancer or other skin conditions
At what age did they develop?
What should you ask in the social hx of someone with a new skin lesion?
Smoking and alcohol
Diet
Have they ever lived outside of the UK?
Do they regularly travel abroad?
How does their skin react to sun - do they tan or burn? How may sunburns have they had?
What so they do for work - outdoor occupation?
Have they ever used sunbeds?
How should you approach a systematic dermatological examination?
Inspect – Observe the overall appearance of the lesion i.e. site, number, pattern of distribution
Describe – Inspect the individual lesions i.e. size, colour, morphology.
Palpate – Feel the texture, temperature, tenderness, consistency and mobility.
Expose – Thoroughly examine the other systems as appropriate i.e. nails, hair, mucous membranes and any other body system required.
How may skin lesions be distributed?
Acral distribution: distal areas including hands and feet (e.g. hand, foot and mouth disease)
Extensor distribution: extensor surfaces incl elbows and knees (e.g. psoriasis)
Flexural distribution: flexural surfaces (e.g. eczema)
Follicular distribution: affecting areas with increased numbers of sebaceous glands such as the face, chest and axillae (e.g. acne)
Dermatomal distribution: confined to one or several dermatomes and do not cross the midline (e.g. herpes zoster).
How should you inspect a skin lesion?
Size
Colour
Configuration
Morphology
What should you look at when screening for features suggestive of malignant melanoma using the ABCDE criteria?
Asymmetry
Border irregularity
Colour variation or changes
Diameter
Elevation/evolution
What is the configuration of a skin lesion?
Configuration refers to the shape or outline of skin lesions
Give 6 examples of how to describe configuration of a skin lesion
Discrete lesions: clearly separated from one another (e.g. normal mole).
Confluent lesions: merging together (e.g. urticaria).
Linear lesions: lesions in the shape of a line (e.g. excoriations).
Discoid lesions: coin-shaped lesions (e.g. discoid eczema, discoid lupus).
Target lesions: concentric rings resembling a bullseye (e.g. erythema multiforme).
Annular lesions: ring-like lesions (e.g. tinea corporis).
Give 4 examples of how you would describe the colour of a skin lesion
Hyper or hypopigmented:
* Hyperpigmentation may be diffuse (e.g. Addison’s) or discrete (e.g. linea nigra in pregnancy)
* An example of hypopigmentation would be pityriasis versicolor as opposed to vitligo which is DEpigmentation
Erythematous (blanching redness)
Purpuric (non-blanching redness)
* Petechiae are spots (less than 2mm)
* Purpura are usually below 10mm
* Ecchymoses/bruises are usually above 10mm
How could you describe a flat lesion?
Macule: less than 5mm
Patch: more than 5mm
How could you describe a mildly raised lesion?
Plaque: more than 1 cm of skin which is usually slightly elevated from the skin
Wheal/weal: dermal oedema causing blanching erythema with central paleness usually a feature of urticaria
How could you describe an elevated lesion?
Papule: solid lesion less than 5mm
Pustule: pus filled papule
Vesicle: fluid-filled papule
Nodule: solid lesion more than 5mm
Abscess: pus-filled nodule
Bullae: fluid-filled nodule
How can you describe the surface of skin lesions?
Scaling or hyperkeratosed
Crusting: yellow or bloody dried discharge
Excoriated (itched)
Granular (fibrous healing tissue)
Lichenification (thickened skin from rubbing)
Ulcers
What are you assessing for on palpation of a skin lesion?
Consistency
Fluctuance
Mobility: assess if the lesion feels mobile or is tethered to other local structures
Tenderness
What are you looking for in the hands in a dermatology examination?
Nail pitting: punctate depressions of the nail plate associated with eczema, psoriasis and alopecia areata.
Onycholysis: separation of the distal end of the nail plate from the nail bed associated with psoriasis and fungal nail infection.
Koilonychia: spoon-shaped nails, associated with iron deficiency anaemia (e.g. malabsorption in Crohn’s disease).
What are you looking for on the elbows in a dermatology examination?
psoriasis plaques, xanthomas (hyperlipidaemia) or rheumatoid nodules (rheumatoid arthritis)
What are you looking for on the scalp in a dermatology examination?
Hair loss:
Alopecia areata
Alopecia totalis
Excess hair growth
Hirsutism: androgen-dependent excess hair growth in females.
Hypertrichosis: non-androgen-dependent excess hair growth.
Scalp:
Scalp psoriasis
Seborrhoeic dermatitis
What are you looking for on the mucous membranes in a dermatology examination?
Hyperpigmented macules: pathognomonic for Peutz-Jeghers syndrome
Bullae: associated with bullous pemphigoid, and pemphigus vulgaris, both autoimmune blistering disorders.
Whickham’s striae: a sign of lichen planus and can be in the buccal mucosa, but also on the genital skin.
What further investigations may you propose after you finish your dermatology exam?
Local lymph node assessment
Swabs/skin scrapings of lesions: for microbiology, virology and fungal culture.
Dermatoscopy of lesions: to more accurately assess a skin lesion
Perform a biopsy of the skin lesion: for histological analysis.
