Skin and Nail Examination Flashcards
1
Q
When examining the skin what are we recording?
A
Description Distribution Pattern (Annular, reticulated, serpiginous, grouped ) Palpation (Consistency, tenderness, temperature, mobility)
2
Q
What are some descriptive terms meanings? Bulla, nodule, papule, macule, purpura
A
- Bulla, An area of skin covered by a raised, fluid-filled bubble. - Nodule, a small swelling or aggregation of cells in the body, especially an abnormal one. -Papule, A papule is a raised area of skin tissue that’s less than 1 centimeter around. A papule can have distinct or indistinct borders. It can appear in a variety of shapes, colors, and sizes. It’s not a diagnosis or disease. Papules are often called skin lesions, which are essentially changes in your skin’s color or texture -Macule, A macule is a flat, distinct, discolored area of skin less than 1 centimeter -Purpura, Purpura is the name given to the discolouration of the skin or mucous membranes due to haemorrhage from small blood vessels.
3
Q
What sort of history do we take for skin?
A
-sun exposure as child (particularly in Australia) -Family melanoma history (10%)
4
Q
What history of a lesion do we get?
A
- Ask ‘When was the lesion first noticed? Is it new?’ 2. Ask ‘Has the lesion changed in appearance?’ 3. Ask ‘Any itching or bleeding?’ 4. Ask ‘Has this lesion or any other pigmented lesion been biopsied or excised?’ 5. Inspect the lesion: note whether symmetrical or not, regular or irregular border, raised or not, pigmentation uniform or variable and any ulceration or inflammation. Measure its size. 6. Inspect the skin all over the body including in the hair for other pigmented lesions. Inspect the draining lymph nodes if melanoma is suspected. 7. Present the ABCDE checklist.
5
Q
Mucosal Conditions
Pemphigoids?
A
Affects lower levels of the skin
- Bullous Pemphigoid (>50 M=F)
- Is an autoimmune subepidermal blistering disease. May have trigger
- 10% mucosal surfaces Buccal > soft palate > gingiva > dorsal tongue. Flexural sites, trunk
- Tense bullae, Pruritis - excoriated, eczematous, papular lesion.
- There is an association with human leukocyte antigen (HLA) indicating a genetic predisposition to the disease.
- associated with infection increases morbidity and mortality
- Mucous membrane pemphigoid (>70)
- Erythematous bullae, erosions, ulcerations, scarring
- Oral and genital mucosa > nasopharynx > oesophagus > eyes
- autoantibodies react with proteins found in mucous membranes and skin tissue resulting in blistering lesions. The binding site appears to be within the anchoring filaments that help the epidermis stick to the dermis.
- autoimmune disease that is characterised by blistering lesions on mucous membranes
6
Q
Mucosal Conditions
Pemphigus?
A
Affects upper layers of epidermis
- Pemphigus Vulgaris (30-60s, 70% of pemphigus)
- Autoimmune genetic condition. rare characterised by painful blisters and erosions on the skin and mucous membranes, most commonly inside the mouth
- keratinocytes are cemented together at unique sticky spots called desmosomes. In pemphigus vulgaris, immunoglobulin type G (IgG) autoantibodies bind to a protein
- Flaccid blisters and erosions
- Buccal mucosa > palate > ventral tongue > lips. Followed by cutaneous lesions
- Paraneoplastic Pemphigus
* Malignant blistering condition
* Skin lesions mimic lichen planus, PV, EM
* Multiple painful erosions with crusting
7
Q
What is linear IgA Bullous Dermatosis?
A
Linear IgA Bullous Dermatosis
- Age < 5 or > 60
- Pruritic, annular vesiculobullous lesions
- Elbows, knees, genitalia, oral mucosa
- Palate > tonsils > buccal mucosa
- Its name comes from the characteristic findings on direct immunofluorescence of a skin biopsy, in which a line of IgA antibodies can be found just below the epidermis.
- Round or oval blisters filled with clear fluid may arise from normal-looking skin or from red flat or elevated patches. The blisters may be small (vesicles) or large (bullae). Typically, the blisters are arranged in rings (annular lesions) and they may form a target shape.
8
Q
Lichen Planus (OLP)
A
- >40 years, 10% affect nails
- Inflammatory affecting hair, skin, nails, mucosal surfaces
- Reticular, erosive, plaque-like, popular, atrophic, bullous
- Buccal mucosa > gingiva > tongue
- chronic inflammatory skin condition affecting the skin and mucosal surfaces. There are several clinical types of lichen planus that share similar features on histopathology.
The mouth is often the only affected area. Oral lichen planus often involves the inside of the cheeks and the sides of the tongue, but the gums and lips may also be involved. The most common patterns are:
- Painless white streaks in a lacy or fern-like pattern
- Painful and persistent erosions and ulcers (erosive lichen planus)
- Diffuse redness and peeling of the gums (desquamative gingivitis)
- Localised inflammation of the gums adjacent to amalgam fillings.
9
Q
Mucosal Conditions
Psoriasis?
A
- Chronic inflammatory disease with papules and plaques with silvery scales
- 2-4% of F and M, mean age 20 and 40.
- Oral mucosa – uncommon
- Generalised pustular psoriasis
- Psoriasis is multifactorial. It is classified as an immune-mediated inflammatory disease (IMID).
- histocompatibility complex HLA-C*06:02 (previously known as HLA-Cw6)
10
Q
Mucosal lesions
Steven Johnsons Syndrome
A
- Stevens–Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are now believed to be variants of the same condition
- Diffuse erythema with blistering
- Flat target lesions with mucosal involvement
- SJS/TEN is a very rare complication of medication use
- There are HLA associations in some races to anticonvulsants and allopurinol.
Polymorphisms to specific genes have been detected (eg, CYP2C coding for cytochrome P450 in patients reacting to anticonvulsants).
11
Q
Mucosal Lesion
-HSV Lesions
A
- Erythema multiforme is herpes simplex virus (HSV) infection
- EM cutaneous with target like lesions
- Labial mucosa, gingiva, vermillion border
- Erythematous macules, vesiculobullous lesions
12
Q
What is Pruritus lesions?
A
- ‘Itch’
- Scratch marks
- Localised – dermatological condition
- Generalised – primary skin disease, systemic illness
- Excoriations/scratching
Primary skin disorders:
- Asteatosis
- Atopic dermatitis
- Urticaria
- Scabies
- Dermatitis herpetiformis
Systemic conditions:
- Cholestasis
- Chronic renal failure
- Pregnancy
- Lymphoma and other internal malignancies
- Iron deficiency, polycythemia rubra vera
- Endocrine disorders ie DM, hypo/hyperparathyroidism
13
Q
Erythosquamous Eruptions
A
- Red and scaly
- Well defined or diffuse borders
- Itchy or asymptomatic
- Hx taking, timeline, family history
- Presence of itch
- Itch – lichen planus
- Associated with primary biliary cirrhosis, GVHD, drug induced
- No itch – secondary syphilis
- Itch – lichen planus
Causes:
- Psoriasis
- Atopic eczema
- Pityriasis rosea
- Nummular eczema
- Contact dermatitis
- Dermatophyte infections
- Lichen planus
- Secondary syphilis
14
Q
Blistering Eruptions?
A
- Presence of vesicles or blisters
- Dermatitis may present as blistering eruptions
Causes
- Traumatic blisters/burns
- Bullous impetigo
- Viral blisters (HSV, varicella)
- Acute contact dermatitis
- Insect bites
- Bullous pemphigoid
- Pemphigus vulgaris
- Dermatitis herpetiformis
- Porphyria cutanea tarda
15
Q
Erythroderma
A
- Red raised lesions
- Can be widespread or localised
- Inflammatory process w/ exfoliation
- Systemic manifestations i.e. peripheral oedema, tachycardia need medical management
Causes:
- Eczema
- Psoriasis
- Drug induced (phenytoin, allopurinol)
- Mycosis fungiodes, leukemia
- Lichen planus
- Hereditary disorders
- Dermatophytosis
- Toxic shock syndrome
17
Q
Dermal plaques?
A
- Localised thickening of skin
- Changes in dermis or subcutaneous fat
- Chronic inflammatory process or sclerotic process
Causes:
- Granuloma annulare
- Necrobiosis lipoidica
- Sarcoidosis
- Erythema nodosum
- Lupus erythematosus
- Morphoea and scleroderma
- TB
- Leprosy
18
Q
Erythema Nodosum
A
- Panniculitis diseases
- Inflammation of subcutaneous fat
- Erythematous, palpable tender
- Lower limbs
Causes:
- Sarcoidosis
- Streptococcal infections
- IBS
- Drugs (sulphonamides, penicillin)
- TB
- Infectious causes i.e. leprosy, histoplasmosis
- SLE
- Behcet’s syndrome
