skin And Endocrine System Flashcards
THE HISTORY
Skin problems which bring a patient to see his doctor can be grouped into two name em
:
1. Localised blemishes and abnormalities which although minor may loom very large in the patients mind, together with skin tumours both
benign and malignant.
2. More generalised eruptions and also problems with skin appendages such as sweat glands,
hair or nail and sabeceous glands.
How is the history of a skin disease taken?
State Suzy presenting complaints a patient can come w about a skin disease ?
State ten questions to ask as a summary of the history?
Presenting Complaint
Find out the patient presenting complaint. Has he come to see the doctor because of the rash or he has other symptoms as well. Is the condition spreading rapidly? Did he notice the skin lesion or somebody pointed it out to him?
These include: • a rash: scaly, blistering or itchy • a lump or lesion • pruritus (itch) • hair loss or excess hair (hirsutism, hypertrichosis) • nail changes.
Duration
Try and get an accurate idea of the duration of the skin condition. Patients tend to under-estimate the length of time such lesion have been present.
Nature of the Lesion
What exactly did the patient notice first? Was it something visible that was noted by chancee when the patient undressed? Did symptoms such as itching or soreness develop before there was anything visible? What did the original lesion look like?
Subsequent Change
What has happened to the lesions since they started? Have the original ones disappeared and been replaced by others or has there been relentless spread. Do the lesions come in crops?
Is there a pattern to their spread? Has the lesion got a centripetal (Centripetal distribution: greatest concentration of lesions on the trunk(The torso of the human body, from the neck to the groin — but not including the head, neck, arms, or legs — is sometimes referred to as the trunk. If you have hives on your trunk, you probably itch on your back, chest and abdomen.) , fewest lesions on distal extremities. May involve the face/scalp. ) or a centrifugal distribution?(Centrifugal distribution: greatest concentration of lesions on face and distal extremities.)
Associated Symptoms
The presence of pain, weeping, bleeding and above all, itching should be noted. If present the periodicity of the itching and exacerbating and relieving factors must also be noted.
Topical Application
Ask what the patient has been applying to the skin. Patients often apply some topical preparations on the skin rash before seeking medical attention. What one actually sees may be the result of self medication or inappropriate therapy. The original condition may have long since undergone spontaneous resolution.
General History
Ask about the patient’s previous skin diseases. Ask about other illness both past and present and any medication that was given. Ask about the patient’s occupation and hobbies, as these may be the source of the trouble. Also ask any travels both within and outside the country.
Ask:
• When did the lesion appear or the rash begin?
• Where is the rash/lesion?
• Has the rash spread, or the lesion changed, since its
onset?
• Is the lesion tender or painful? Is the rash itchy? Is the itch
intense enough to cause bleeding by scratching or to disturb sleep, as in atopic eczema and lichen simplex? Are there blisters?
• Do the symptoms vary with time? For example, the pruritus of scabies is usually worse at night, and acne and atopic eczema may show a premenstrual exacerbation.
• Were there any preceding symptoms, such as a sore throat in psoriasis, a severe illness in telogen effluvium, or a new oral medication in drug eruptions?
• Are there any aggravating or relieving factors? For example, exercise or exposure to heat may precipitate cholinergic urticaria.
• What, if any, has been the effect of topical or oral medications? Self-medication with oral antihistamines may ameliorate urticaria, and topical glucocorticoids may help inflammatory reactions.
• Are there any associated constitutional symptoms, such as joint pain (psoriasis), muscle pain and weakness (dermatomyositis), fever, fatigue or weight loss?
• Very importantly, what is the impact of the rash on the individual’s quality of life?
On inspection of a skin disease,what 11 things should you check for in the body, what seven things should you take notice of concerning distribution of lesions?
What is hypopigmentation ? What can cause it?
What can hypopigmentation indicate?
What two things can the distribution of a lesion suggest ?
What is distribution?
The localisation of multiple lesions in certain regions helps diagnosis, as skin diseases tend to have characteristic distributions. True or false
Where do you note the presence ont contact dermatitis?
What is the distribution of skin lesions in contact dermatitis ?
After checking the distribution what else do you check Under inspection ?
What do you check the scalp for?
After checking the scalp what do you check?
What three things will you look at the nails and nail folds for
What will you look in between the fingers for?
Burrows appear where?
Where is scabies most often found in adults and older children?
What does a Scabies rash look like ?
How do they appear?
What can it cause on your skin
What two things will you look under the breasts for ?
What is intertrigo
What will you look in between the toes for?
State three common causes of genital rashes
What is the characteristic of a genital rash ?
What is diaper rash
What is the perineum
What is a perineal lesion
What are skin lesions
INSPECTION
1.Distribution of Lesions
In order to carry out a proper examination of the sin the patient should be fully undressed within the limits of decency. a.Note any hypopigmentation (Hypopigmentation refers to patches of skin that are lighter than your overall skin tone. Your skin’s pigmentation, or color, is based on the production of a substance called melanin. If your skin cells don’t produce enough melanin, the skin can lighten. These effects can occur in spots or may cover your entire body.)(seen in fungal infection)
b.hyperpigmentation or general redness (erythroderia).
c.What is the pattern of the lesions on the skin surface?
d.Are they for example symmetrical or just affecting exposed areas?
e.If so does the distribution suggest photosensitivity(Photosensitive — increase in the reactivity of the skin to sunlight. )or a reaction to external factors?
Distribution refers to how the skin lesions are scattered or spread out. f.Skin lesions may be isolated (solitary or single) or multiple.
g.Note the presence of contact dermatitis. in the dorsum of the feet with wearing shoes/sandals made with allergic substance or ear rings or necklaces to which the patient is allergic.
The distribution of the rash gives the game away.(Contact dermatitis is a common inflammatory skin condition characterized by erythematous and pruritic skin lesions after contact with a foreign substance. The condition can be categorized as irritant or allergic.)
2.
Examine the surface of the scalp for fungal infection, alopecia and scarring. 3.Look behind the ears and the external auditory meatus .(auricle and external auditory meatus form the outer ear) .
4.Include an inspection of the mouth. 5.Raise the arm and inspect the axilla.
6.Look at the nails and nailfolds for clubbing, pitting of the nails and fungal infection of the nails.
Look in between the fingers for the burrows of scabies. The burrows or tracks typically appear in folds of skin. Though almost any part of the body may be involved, in adults and older children scabies is most often found: Between the fingers. In the armpits.
scabies rash looks like blisters or pimples: pink, raised bumps with a clear top filled with fluid. Sometimes they appear in a row. Scabies can also cause gray lines on your skin along with red bumps. Your skin may have red and scaly patches
7. Look under the breasts for intertrigo (Skin inflammation, usually in warm, moist areas, such as the groin or between skin folds. )
and fungal infection(yeast overgrowth in the skin between or under your breasts is a type of intertrigo. Intertrigo is a rash that forms in skin folds. Intertrigo can also be caused by bacteria and other fungus.)
8. gaze into the depths of the umbilicus.
9.Look at the feet and in between the toes for fungal infection e.g. athletes foot.
10.Finally look at the genitalia (Some of the most common causes of genital rashes are infections: Jock itch, a fungal infection, or ringworm of the groin area. The rash is red, itchy, and scaly, and it may blister.
Diaper rash, a yeast infection that affects babies because of the warm, moist environment in diapers )
11.and perianal area for any skin lesion.(The perineum is the area of skin between the vagina and anus in women and … ranging from skin irritation to underlying medical conditions.What is a perineal lesion?
Perianal lesions are those that can be completely visualized without buttock traction within a 5 cm radius of the anal opening. Skin lesions are those that fall outside the 5 cm radius of the anal opening)
After inspection of the lesions,what else should you look at?
What is a macule and give an example
What is a papule,a plaque ,a nodule ,
What produces a weal? Give two examples of a weal. What are hives?
What triggers hives ?
Fluid filled blisters on the skin are divided on the basis of what? Into what?
Blistering is an important physical sign. State two which conditions cause blistering
What is pemphigus? What does it cause? Where can it affect? What’s the most common type of it?
Pustules contain what? Pustules do not automatically indicate what?
Pustules of which condition are sterile?
What is a pustule?
What produced crusts or scab?
What produced scars
What is scaling
What is ichtyoses
Scaling may be the only visible change in which disease or may be accompanied by inflammation as in which disease
Most cases of ichthyosis are inherited, but some types develop in association with genetic syndromes or diseases, such as Hodgkin’s lymphoma.) true ir false
Another name for scaling is ?
What is desquamation
Desquamation can follow which three things?
Morphology:
Look closely at the lesions and determine their morphology
. 1.A macule is a lesion which can be seen easily but is impalpable e.g. a freckle.
2.When a lesion can be felt a well as seen, it may be described as a papule or if more extensive a plaque or if deeper a nodule.
3.Dermal edema with no overlying epidermal change produces a weal e.g. urticaria or hives(skin rash triggered by a reaction to food, medicine or other irritants.Hives is a common skin rash triggered by many things, including certain foods, medication and stress.) 4.Fluid filled blisters on the skin are arbitrarily divided on the basis of size into smaller vesicles, medium blisters and large bullae. Blistering is an important physical sign. A number of conditions always blister such as pemphigus(Pemphigus is a rare group of autoimmune diseases. It causes blisters on the skin and mucous membranes throughout the body. It can affect the mouth, nose, throat, eyes, and genitals. Pemphigus vulgaris is the most common type of pemphigus. )
others occasionally so as like erythema multiforme(A skin disorder characterised by bull’s-eye-shaped lesions.
The cause of erythema multiforme isn’t well understood, but it may be triggered by an infection..
5.Pustules contain debris, leukocytes and micro-organisms as well fluid but do not automatically indicate infection; the pustules of psoriasis for example are sterile.(pustule is a bulging patch of skin that’s full of a yellowish fluid called pus. It’s basically a big pimple, Several conditions, ranging from something as common as acne to the once-deadly disease smallpox, can cause pustules.)
6.Where the epidermis is lost an erosion is formed the consequent oozing of serous fluid when this dries produces crusts or scab. Erosion will heal without damage to the skin but ulcers produced by penetration into the dermis will heal to give scarring.
7.Scaling is the accumulation of keratin, either normal or abnormal, on the skin surface. It may be the only visible change, as in some ichtyoses(A group of skin disorders characterised by dry, scaly or thickened skin.
or accompanied by inflammation as in psoriasis.
Scaling is also called desquamation Shedding of the horny layer is termed desquamation and can follow an inflammatory disorder such as exanthema(, skin rash accompanying a disease or fever.), drug reaction or underlying cellulitis.
After checking the morphology of the lesions under inspection what else should you check for ?
Some disorders give rise to lesions with a clear-cut division between normal and abnormal skin whereas in others the abnormal blends into the normal.
True or false
What indicates the direction of spread?
What is a scalloped margin?
Which disease has a rash with raised red borders whose outer edge resembles the shape of a scallop shell
Lichen planus is characteristically limited by what?
When does Lichen planus occur
What is an annular lesion
What represents the most common presentation of annular lesions?
Apart from annular,lesions may be what other types?
How is an annular lesion formed
This is typical of which disease?
Linearity if a lesion may imply what or what?
What is Koebner phenomenon
This occurs mostly in which diseases
Outline:
The margin of the individual lesion should be carefully examined.
Generally a convex border indicates the direction of spread.
Where multiple small lesions have coalesced( come together to form one mass or whole. )to produce larger patches the margin will appear scalloped. (Having a boundary or border shaped in a series of connected waves or C-shapes. Some rashes (like the rash of cutaneous T-cell lymphoma) have raised red borders whose outer edge resembles the shape of a scallop shell.)
Lichen planus is characteristically limited by fine skin creases producing polygonal lesions. (An inflammatory condition of the skin and mucous membranes.
Lichen planus occurs when the immune system mistakenly attacks cells of the skin or mucous membranes ) If the skin in the centre of a lesion returns to normal as it spreads an annular lesion is formed (Annular skin lesions are figurate lesions characterized by a ring-like morphology. Although plaques represent the most common presentation of annular lesions, lesions may also be macular, nodular, or composed of grouped papules, vesicles, or pustules ). This is typical of ringworm but it is not pathognomonic. (Indicative of a particular disease or condition)
Linearity may imply either an underlying structural defect or a response to external factors applied to the skin in a linear fashion such as occurs in the Koebner phenomenon.
(The Koebner phenomenon describes the appearance of new skin lesions of a pre-existing dermatosis on areas of cutaneous injury in otherwise healthy skin. It is also known as the Köbner phenomenon and isomorphic response ). This occurs most commonly in psoriasis and lichen planus,vitiligo
After checking the outline of a lesion under Inspection what else should you check
Very bright red erythema indicates what?
As activity begins to decline,what happens to the lesions and the redness?
After colour what else should you check for under inspection?
What three things are you to check for under the answer in the previous question
White scales are seen in which lesions of which disease
Colour
Colour changes in dark skins may be difficult as redness may not be so obvious. As a general rule very bright red erythema indicates an active disorder and as activity begins to decline the lesions become paler, sometimes with the redness being replaced by post inflammatory pigmentation.
Texture
a.Is the surface of the lesion scaling or not? b. If it is difficult to determine the removal of surface grease, using a little ether is helpful. c.If scaling is present and makes it difficult to see the base of the lesion a little oil can be applied to the surface. White scales are seen typically in the discoid lesions of psoriasis.
What you should you check for under palpation
If the skin is thickened,identify whether it’s the epidermis is thickened or the dermis is thickened true or false
The lesion may spread much further than is evident visually as what or what? Give an example of a disease where this happens
In erythema nodosum the red nodules on the skin are what?
What is Erythema nodosum
What does it result in
State six causes of this erythema nodosum
What’s the difference between crusts and keratin
Any scale should be tested for what?
PALPATION
Palpation should never be omitted. It can be a great relief to the patient to know that one is not afraid to tough their skin. Relatives and friends may keep a discrete and their sex lives may be nonexistent so the last thing they want is a medical adviser who confirms their untouchability.
Palpation also conveys a lot of information. 1.The skin may be thickened in which case it should be possible to identify whether it is the epidermis which is thickened (lichenified) or the dermis.
The lesion might spread much further than is evident visually, as calcified or cystic, cooler or warmer than the surrounding skin, as in erythema nodosum or atrophic with loss of dermal collagen.
2.Note any tenderness; in erythema nodosum the red nodules in the skin of the legs are painful. Erythema nodosum is a type of skin inflammation that is located in a part of the fatty layer of skin. Erythema nodosum results in reddish, painful, tender lumps most commonly located in the front of the legs below the knees. Causes of erythema nodosum include infections like streptococcus, tuberculosis, leprosy, deep mycosis and cattle ringworm. Other causes are sarcoidosis, Crohn’s disease, and ulcerative colitis. The rest are drugs like sulphonamides and malignancies; especially after radiotherapy. Erythema nodosum may be persistent and the cause is unknown.
Crusts when present should be removed from the sample area so the underlying surface can be inspected. As crusts are not firmly adherent to the surface, the simplicity of removal will also help to distinguish them from keratin, which is an integral part of the lesion and can rarely be removed with ease. Any scale should be tested for silveriness which is pathognomonic of psoriasis.
What are the three layers of the skin What is the epidermis What are Langerhans cells Which layer is the most anatomically complex layer ? State nine things the dermis contains The deep subcutis contains what? State five functions of the skin
It has three layers, the most superficial of which is the epidermis, a stratified squamous epithelium, containing melanocytes (pigment-producing cells) within its basal layer, and Langerhans cells (antigen-presenting immune cells) throughout.
The dermis is the middle and most anatomically complex layer, containing vascular channels, sensory nerve endings, numerous cell types (including fibroblasts, macrophages, adipocytes and smooth muscle), hair follicles and glandular structures (eccrine, sebaceous and apocrine), all enmeshed in collagen and elastic tissue within a matrix comprising glycosaminoglycan, proteoglycan and glycoprotein.
The deep subcutis contains adipose and connective tissue.
Dermatoses (diseases of the skin) may affect all three layers and, to a greater or lesser extent, the various functions of the skin.
14.1 Functions of the skin
• Protection against physical injury and injurious substances, including ultraviolet radiation
• Anatomical barrier against pathogens
• Immunological defence
• Retention of moisture
• Thermoregulation
• Calorie reserve
• Appreciation of sensation (touch, temperature, pain)
• Vitamin D production
• Absorption – particularly fetal and neonatal skin
• Psychosexual and social interaction
State two functions of hair and the two main types of hair
When do abnormalities in hair distribution occur?
Hair loss occurs as a result of what disorders ?
Fingernail regrowth takes how many months? Toenail regrowth takes how many months
Hair
Hair plays a role in the protective, thermoregulatory and sensory functions of skin, and also in psychosexual and social interactions. There are two main types of hair in adults:
• vellus hair, which is short and fine, and covers most of the
body surface
• terminal hair, which is longer and thicker, and is found on
trunk and limbs, as well as scalp, eyebrows, eyelashes, and pubic, axillary and beard areas.
Abnormalities in hair distribution can occur when there is transitioning between vellus and terminal hair types (for example, hirsutism in women) or vice versa (androgenic alopecia).
Hairs undergo regular asynchronous cycles of growth and thus, in health, mass shedding of hair is unusual. Hair loss can occur as a result of disorders of hair cycling, conditions resulting in damage to hair follicles (such as purposeful removal in trichotillomania), or structural (fragile) hair disorders.
Nails
The nail is a plate of densely packed, hardened, keratinised cells produced by the nail matrix. It serves to protect the fingertip and aid grasp and fingertip sensitivity. The white lunula at the base of the nail is the visible distal aspect of the nail matrix (Fig. 14.2). Fingernail regrowth takes approximately 6 months, and toenail regrowth 12–18 months
After asking the ten or so questions about the skin rash or lesion or whatever
What are you to ask under past medical and drug history ?
A history of which diseases suggest atopy?
Coeliac disease is associated which what disease?
Past medical and drug history
Ask about general health and previous medical or skin conditions; a history of asthma, hay fever or childhood eczema suggests atopy.
Coeliac disease is associated with dermatitis herpetiformis.
Take a full drug history, including any recent oral or topical prescribed or over-the-counter medication. Enquire about allergies not just to medicines but also to animals or foods.
What is Fitzpatrick scale of skin types?
14.2 Fitzpatrick scale of skin types
The susceptibility of an individual to sun-induced damage can be determined by defining their skin type using the Fitzpatrick scale (Box 14.2)
- Type 1: always burns, never tans
- Type 2: usually burns, tans minimally
- Type 3: sometimes burns, usually tans
- Type 4: always tans, occasionally burns
- Type 5: tans easily, rarely burns
- Type 6: never burns, permanent deep pigmentation
What are you to ask under family and social history of skin disease ?
Exposure to chemicals may cause what skin disorder ?
Why will you document foreign travel and sun exposure ?
Sun exposure causes the increased risk of what diseases?
Insee sun exposure leads to what?
The history of a skin disorder alone rarely enables a definite diagnosis, with perhaps the occasional exception? What’s the exception ?
What rash is likely to be urticaria
What characteristic of rash is considered to be scabies until proven otherwise?
Family and social history
Enquire about occupation and hobbies, as exposure to chemicals may cause contact dermatitis.
If a rash consistently improves when a patient is away from work, the possibility of industrial dermatitis should be considered. Ask about alcohol consumption and confirm smoking status.
Document foreign travel and sun exposure if actinic damage, tropical infections or photosensitive eruptions are being considered.
The risk of squamous cell and basal cell cancers increases with total lifetime sun exposure, and intense sun exposures leading to blistering burns are a risk factor for melanoma..
Ask about a family history of atopy and skin conditions.
an itchy eruption that resembles a nettle rash, the individual components of which last less than 24 hours, is very likely to be urticaria; and an intensely itchy eruption that affects all body areas except the head (in adults) and is worse in bed at night should be considered to be scabies until proved otherwise.
What is the approach to physical exam of skin disease
The patient should ideally be undressed to their underwear. Routinely, the hair, nails and oral cavity should be examined, and the regional lymph nodes palpated. Assess skin type using the Fitzpatrick scale
In documenting the appearance of a lesion or rash, use the correct descriptive terminology doing so often helps crystallise the diagnostic thought processes.
What does a symmetrical distribution indicate
What does an asymmetrical distribution indicate
What is the exception to this rule
What is the pattern of rash in atopic eczema,psoriasis,lichen planus,seborrhoeic dermatitis,photosensitive eruptions
Which disease rash follows the dermatomes
Which disease rash follows Langers lines of skin tensions
Which disease follows Blaschko lines?
What is the pattern of rash in sarcoidosis
Which disease has the tendency to involve the shins
The distribution of a dermatosis can be very informative. Is the eruption symmetrical? If so, it is likely to have a constitutional basis, and if not, it may well have an extrinsic cause. This golden rule has occasional exceptions (such as lichen simplex)
but holds true in the majority of instances. Its application will almost always prevent the common misdiagnosis of ‘bilateral cellulitis’ (bacterial infection) of the legs, which in actuality is usually lipodermatosclerosis or varicose eczema; bacteria are not known for their sense of symmetry!
The pattern of a rash may immediately suggest a diagnosis: for example, the antecubital and popliteal fossae in atopic eczema (Fig. 14.3A); the extensor limb surfaces, scalp, nails and umbilicus in psoriasis (Fig. 14.3B); the flexural aspects of the wrists and the oral mucous membranes in lichen planus; the scalp, alar grooves and nasolabial folds in seborrhoeic dermatitis; and the sparing of covered areas in photosensitive eruptions. Does the rash follow a dermatome (as with shingles), or Langer’s lines of skin tension (as with pityriasis rosea), or Blaschko (developmental) lines (as with certain genetic disorders)? The localisation of an eruption to fresh scars or tattoos may be a manifestation of sarcoidosis, and the anatomical location may provide a clue to diagnosis, such as the tendency of erythema nodosum, pretibial myxoedema and necrobiosis lipoidica (Fig. 14.4) to involve the shins.
What is the morphology of a rash caused by lichen planus
Koebner phenomenon results in what? And occurs par excellence in which four diseases?
Linear or angular markings raise the likelihood of what ?
Presence of blisters limits diagnostic possibilities to what four groups of disorders and give examples under each
An annular morphology mag be seen in which three diseases
The vascular contribution to the colour of a rash can be pivotal in diagnosis since erythematous and purpuric eruptions usually have very different underlying causes. It is not sufficient to describe a rash as ‘red’ or ‘pink’; it is essential to demonstrate whether or not a rash blanches on direct pressure or when the skin is stretched
True or false
Blanchable redness indicated what?
Non blanchable redness indicated what?
What tint of erythema indicated lichen planus?
Which tint of erythema indicates psoriasis
Which tint of erythema indicates dermatomyositis?
Macular purpura may be the result of ?
Palpable purpura indicates what?
Purpura elicited by pinching the skin may be indicative of what disease
phology of a rash
The morphology (shape and pattern) of a rash is equally important. Violaceous, polygonal, flat-topped papules, topped by a lacy patterning (Wickham striae), are typical of lichen planus (Fig. 14.5). The Koebner (isomorphic) phenomenon, where a dermatosis is induced by superficial epidermal injury, results in linear configurations (Fig. 14.6A), and occurs par excellence in psoriasis, lichen planus, viral warts and molluscum contagiosum.
Linear or angular markings (erythema or scarring) raise the likelihood of artefactual (self-inflicted) damage to the skin. The presence of blisters limits the diagnostic possibilities to a relatively small number of autoimmune (such as dermatitis herpetiformis, pemphigoid (Fig. 14.6B) and pemphigus), reactive (including
erythema multiforme, Stevens–Johnson syndrome and toxic epidermal necrolysis), infective (such as bullous impetigo and herpes simplex infection) and inherited (for example, epidermolysis bullosa) disorders.
An annular (ring-like) morphology may be seen in granuloma annulare (Fig. 14.6C), subacute cutaneous lupus erythematosus, and fungal infections (‘ringworm’).
. Blanchable redness (erythema) indicates that the red blood cells causing the colour remain within blood vessels; non-blanchable redness (purpura) is the result of erythrocyte
extravasation and entrapment in the collagen and elastic fibres of the dermis.
The tint of the erythema may be helpful: a violaceous hue distinguishes lichen planus; a beefy-red or salmon-pink colour often typifies psoriasis; and a heliotrope (pink–purple) colour is a feature of dermatomyositis, especially on the eyelids.
Macular purpura may be the result of thrombocytopenia or capillary fragility, but palpable purpura (often painful) usually indicates vasculitis (Fig. 14.7A) and necessitates exclusion of vasculitic inflammation in other organs.
Purpura elicitable by pinching the skin (‘pinch purpura’) may be indicative of AL (light-chain) amyloidosis
