Dermatology History and Describing Lesions

Question 1

What questions should you ask in a hx of presenting complaint for a new skin lesion?

Answer 1

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?

Time - has the lesion changed over time?

Exacerbating / Relieving

Severity - can you tell me about the impact that this is having on you?

Question 2

Invovlement of which areas of the body should you screen for in someone with an inflammatory skin condition?

Answer 2

scalp, hair, nails, genitals, joints
eyes and mucosa

Question 3

What should you cover in a systems review for someone with a new skin lesion?

Answer 3

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)

ALSO DO B SXS

Question 4

What triggers should you ask about for someone with a new skin lesion?

Answer 4

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?

Question 5

What conditions should you specifically ask about in the PMH of anyone with an inflammatory skin lesion?

Answer 5

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)

Question 6

What should you ask in the family hx of someone presenting with a new skin lesion?

Answer 6

Any family hx of skin cancer or other skin conditions
At what age did they develop?

Question 7

What should you ask in the social hx of someone with an inflammatory skin lesion / new rash?

Answer 7

Smoking and alcohol
Diet
Occupation - any link to skin problems and work?
Travel hx?
Sexual hx?

Question 8

How should you approach a systematic dermatological examination?

Answer 8

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.

Question 9

How may skin lesions be distributed?

Answer 9

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).

Question 10

How should you inspect a skin lesion?

Answer 10

Size
Colour
Configuration
Morphology

Question 11

What should you look at when screening for features suggestive of malignant melanoma using the ABCDE criteria?

Answer 11

Asymmetry
Border irregularity
Colour variation or changes
Diameter
Elevation/evolution

Question 12

What is the configuration of a skin lesion?

Answer 12

Configuration refers to the shape or outline of skin lesions

Question 13

Give 6 examples of how to describe configuration of a skin lesion

Answer 13

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).

Question 14

Give 4 examples of how you would describe the colour of a skin lesion

Answer 14

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

Question 15

How could you describe a flat lesion?

Answer 15

Macule: less than 5mm
Patch: more than 5mm

Question 16

How could you describe a mildly raised lesion?

Answer 16

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

Question 17

How could you describe an elevated lesion?

Answer 17

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

Question 18

How can you describe the surface of skin lesions?

Answer 18

Scaling or hyperkeratosed
Crusting: yellow or bloody dried discharge
Excoriated (itched)
Granular (fibrous healing tissue)
Lichenification (thickened skin from rubbing)
Ulcers

Question 19

What are you assessing for on palpation of a skin lesion?

Answer 19

Consistency
Fluctuance
Mobility: assess if the lesion feels mobile or is tethered to other local structures
Tenderness

Question 20

What are you looking for in the hands in a dermatology examination?

Answer 20

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).

Question 21

What are you looking for on the elbows in a dermatology examination?

Answer 21

psoriasis plaques, xanthomas (hyperlipidaemia) or rheumatoid nodules (rheumatoid arthritis)

Question 22

What are you looking for on the scalp in a dermatology examination?

Answer 22

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

Question 23

What are you looking for on the mucous membranes in a dermatology examination?

Answer 23

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.

Question 24

What further investigations may you propose after you finish your dermatology exam?

Answer 24

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.

Question 25

How should you approach a history of a suspected skin cancer?

Answer 25

1. Onset: slowly growing vs rapidly growing
2. Changes: Size, shape, and Colour, existing mole?
3. Symptoms: itching, pain, tenderness, crust, bleeding, ulcer (SCCs can be painful)
4. Hx of trauma and burn.
5. Past hx of skin cancers: personal or family

Question 26

What should you aks when assessing risk of a skin cancer?

Answer 26

6. Sun exposure: how much sun exposure would you say you get? sunbathing? tanning beds? how does your skin react to the sun? do you tan or burn? how many burns have you had?
7. Travel hx : living outside the UK, holiday to sunny countries?
8. Hobbies: gardening, walking, jogging etc
9. Occupation: indoor or outdoor
10. Sun protection? SPF50, long sleeves, sunglasses, avoid sun between 11 am and 3 pm, wide brimmed hat etc.
11. Immune status: diabetes, HIV, immune suppressants (steroids, chemo, radio), organ transplants

Question 27

What questions should you ask at the end of any skin cancer history?

Answer 27

any allergies? on any anti-coagulation?

useful to know if you are going to excise it!!!