Skin and Nail Examination Flashcards
When examining the skin what are we recording?
Description Distribution Pattern (Annular, reticulated, serpiginous, grouped ) Palpation (Consistency, tenderness, temperature, mobility)
What are some descriptive terms meanings? Bulla, nodule, papule, macule, purpura
- 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.
What sort of history do we take for skin?
-sun exposure as child (particularly in Australia) -Family melanoma history (10%)
What history of a lesion do we get?
- 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.
Mucosal Conditions
Pemphigoids?
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
Mucosal Conditions
Pemphigus?
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
What is linear IgA Bullous Dermatosis?
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.
Lichen Planus (OLP)
- >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.
Mucosal Conditions
Psoriasis?
- 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)
Mucosal lesions
Steven Johnsons Syndrome
- 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).
Mucosal Lesion
-HSV Lesions
- Erythema multiforme is herpes simplex virus (HSV) infection
- EM cutaneous with target like lesions
- Labial mucosa, gingiva, vermillion border
- Erythematous macules, vesiculobullous lesions
What is Pruritus lesions?
- ‘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
Erythosquamous Eruptions
- 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
Blistering Eruptions?
- 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
Erythroderma
- 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
Pustular Lesions
- Results from accumulation of neutrophils
- Infective process commonly
- Crust – dried serum, blood or pus
- Differentiate bw infectious or inflammatory condition
Causes:
- Acne vulgaris (comedones, papules, pustules, cystic lesions, ice-pick scars—no telangiectasias)
- Acne rosacea (acne-like lesions, erythema and telangiectasias on central face—no comedones)
- Impetigo
- Folliculitis
- Viral lesions
- Pustular psoriasis
- Drug eruptions
- Dermatophyte infections
- Sweet’s syndrome (pustular dermatosis)
Dermal plaques?
- 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
Erythema Nodosum
- 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
Cellulitis ?
- Inflammation of deep dermis and subcutaneous tissue
- Unilateral erythema
- Hallmark inflammatory signs w/ lymphadenopathy
Causes:
- Streptococcus or Staph aureus
May present with:
- Severe pain
- Pale pink skin
- Check signs of sepsis
- Necrotising fasciitis
Pigmentation
- Hyper, hypo or depigmentation
- Underlying systemic disease
- Post inflammatory hyperpigmentation
- Depigmentation – vitiligo
Causes:
- Endocrine
- Addison’s, OCP, pregnancy, thyrotoxicosis
- Metabolic
- Malabsorption, liver diseases, chronic kidney disease
- Genetic
- Racial differences
- Radiation or drugs
Melanocytes
Melanoma is considered a differential
Flushing?
- Menopause
- Hypersensitivity reactions
- Alcohol
- Rosacea
- Carcinoid syndrome
- Autonomic dysfunction
- Medullary carcinoma of thyroid
Skin Tumours
- Very common in our continent
- Hypervigilance for malignancy
Benign:
- Warts
- Seborrhoeic keratosis
- Dermatofibroma
- Neurofibroma
- Angioma
- Xanthoma
Malignant:
- Basal cell carcinoma (most common in aus/nz). Usually non invasive. Exision and cream application (burns it off)
- Squamous cell carcinoma
- Malignant melanoma
- Metastases
What is the ugle duckling rule?
Added in the ‘ugly duckling’ – multiple moles where 1 looks very different to the others
What is the ABCDE Rule?
Asymmetry: •Consistent with more sinister pathology
Boarders: •Are the edges well defined
Colour: •Consistency?
Diameter:•Lesion > 6mm?
Evolution/elevation:
- Changes in shape, size, colour
- Development of symptoms
Nail assessment?
- Nail plate abnormalities
- Pitting, ridging, notching, groove, crumbing, melanoma
- Discolouration
- Subungual melanoma, melanocytic naevus, paronychia, onychomycoses
- Cyanosis, splinter haemorrhage
- Cuticle abnormalities
- Candida, psoriatic nail, vasculitis, telangiectasias
- Shape Abnormalities
- Clubbing, koilonychia, ingrown nail, pincer nail
- Loss of nails
- Nail biting, onchyomadesis, lichen planus
- Around nails
- Myxoid cyst, warts, SCC, pyogenic granuloma
What are some nail disorders?
Onychogryphosis is a nail disease that causes one side of the nail to grow
Angel-wing deformity describes nail plate thinning due to lichen planus.
Trachyonychia is a disorder of the nail unit that most commonly presents with rough, longitudinally ridged nails
Important nail changes to note?
Nail pitting:
- depressions of the nail plate
- eczema, psoriasis and alopecia areata
Onycholysis:
- Separation of the distal end of the nail plate from the nail bed
- psoriasis and fungal nail infection
Koilonychia:
- Spoon shaped indentation of the nail plate
- iron deficiency anaemia, can also be congenital
Nail clubbing:
- Loss of the angle between the posterior nail fold and nail plate
- Associated with many conditions including inflammatory bowel disease, cyanotic heart disease, lung cancer, bronchiectasis
Age changes?
- Loss of elasticity
- Dec in melanocytes à paleness (which makes age spots and liver spots increase)
- Dec in nail plate thickness à fissuring
- Reduction fat and water content à wasting
- Sun exposure à age spots or lentigines
Pregancy skin changes?
Facial and oral:
- Melasma
- pyogenic granuloma
- Acne
- Nevi
- Melanoma
- Hemangiomas
- Other areas:
- Spider nevi
- Palmar erythema
- Varicosities
- Purpura and petechiae
- Onycholysis
whats general exam for every single patient?
- historys,
- EO – neck up and behind the ears.
- Then hands, finger nails and elbows, also look at lips
Moles?
A mole is a common benign skin lesion due to a local proliferation of pigment cells (melanocytes). It is more correctly called a melanocytic naevus
- People with many moles tend to have family members that also have many moles, and their moles may have a similar appearance.
- Somatic mutations in RAS genes are associated with congenital melanocytic naevi.
- New melanocytic naevi may erupt following the use of BRAF inhibitor drugs
Freckles (melanoma – ask if it has changed, has evolved (changed over 3 months?)
Melanoma can spread horizontally then vertically 0.5mm a month is spread.
Amelonocytic melanoma is the most common and is caught late as it not visible
Acne?
Acne is a common chronic disorder affecting the hair follicle and sebaceous gland, in which there is expansion and blockage of the follicle and inflammation. There are several variants.
85% of 16 to 18 year-olds
- Open and closed uninflamed comedones (blackheads and whiteheads)
- Inflamed papules and pustules
- In severe acne, nodules and pseudocysts
- Post-inflammatory erythematous or pigmented macules and scars
- Adverse social and psychological effects.
Severity is classified as mild, moderate or severe.
- Mild acne: total lesion count <30
- Moderate acne: total lesion count 30–125
- Severe acne: total lesion count >125
Management
- Mild acne
- Topical antiacne agents, such as benzoyl peroxide and/or tretinoin or adapalene gel. New bioactive proteins may also prove successful.
- Low-dose combined oral contraceptive
- Antiseptic or keratolytic washes containing salicylic acid
- Light/laser therapy
- Moderate acne
- As for mild acne plus a tetracycline such as doxycycline 50–200 mg daily for 6 months or so
- Erythromycin or trimethoprim if doxycycline intolerant
- Antiandrogen therapy with long-term cyproterone acetate + ethinylestradiol or spironolactone may be considered in women not responding to low-dose combined oral contraceptive, particularly for women with polycystic ovaries
- Isotretinoin is often used if acne is persistent or treatment-resistant
- Severe acne
- Referral to a dermatologist
- If fever, arthralgia, bone pain, ulcerated or extensive skin lesions, blood count should be arranged and referral is urgent
- Oral antibiotics are often used in higher doses than normal
- Oral isotretinoin is usually recommended in suitable patients
What is Roaccutane and what are the effects?
13-cis-retinoic acid
transient worsening of acne (lasting 1–4 months), dry lips (cheilitis), dry and fragile skin, and an increased susceptibility to sunburn.
Dose monitored due to vit A toxicity risk: increases liver enzymes. eg
- Anemia
- Increased red blood cell sedimentation rate
- Thrombocytopenia
- Thrombocytosis
works in the liver and dries out subastious glands- check lips watch medication ragime – liver function tests 6-8 weeks and adjust drug doses
