approach to the patient with skin disease

1. Dermatology
Approach to the patient with skin
disease
By Dr kirtida desai,MD(Homeo)
Professor, HOD-practice of medicine
PG, Phd guide

2. History taking
 Try to get information regarding primary lesion and
secondary lesion of the skin.
 Primary- original picture of skin disease eg tinea,
where ring shaped eruptions are present
 Secondary- same eruption gets altered over period of
time due to constant itching, scratching, scab
formation and some times with secondary infection.
We may find lichenification due to scratching.

3.  Presenting Complaints
 Patients present to the dermatologist with a variety of
complaints,
which can be grouped as:
 Subjective symptoms:
 Which cannot be seen by physician
it include symptoms like itching, pain, and paresthesia etc
Objective symptoms:
Which can be seen by a doctor
it include symptoms like rash, ulcers, hair fall (or
growth),changes in nails, etc.

4. ODP
 For each symptom, the following questions should be
asked:
 Duration: Is the problem acute or chronic? If chronic,
about relapses and remissions.
 Site of first involvement: And spread.
 Evolution: Of lesions.
 Duration
 Diurnal variation: In most dermatoses, itching is
generally more severe at night because the patient’s
mind is not diverted.
 But in sun-induced dermatosis, the itching is logically
worse during day.

5.  Symptoms asociated with eruption, how it’s relieved
 Ailments from-Recent medication, new food eg fish, eggs
etc ,(protein present in these food may cause
hypersensitivity reaction), colouring or preservatives
added in food etc may cause allergy.
 Contact with plants must be inquired
 Associated systemic symptoms, eg fever, malaise,
arthralgia etc
 Ongoing illness like sarcoidosis, restrictive lung disese,
bronchial asthama etc
 h/o allergy
 h/o photosensitivity

6. Subjective symptoms- itching ,
pain, paraesthesia inquire…
 Diurnal variation-
 scabies – agg night
 Photosensitivity only during day
 Seasonal variation-
 Summer- miliary euption, mosquito bite, fungal
infection etc
 Winter- psoriasis, ichthiosis, raynaud’s disease,
Chilblain etc
 Agg of pain in winter in systemic sclerosis

7.  Precipitated by exercise-collinergic urticarea,
intermittant claudication(pain)
 Precipitated by cold- cold urticarea, raynaud’s
phenomena(pain and chilblain)
 Associated symptoms- rash with fever in systemic
disease like measles,
 Wheel- with fever and itching in allergic conditions
 hypopigmented patches eg parasthesia in leprosy
 Pain with rash and eruption- herpes zoster

8.  wheals, cyanosis, gangrene, hypopigmented
lesions, neuritis and sensory impairment.
 Look for nail changes, hair loss, and involvement of
palms, soles, scalp, and mucosae (all!).

9. Objective symptoms
 Location-
 Face, back- acne
 Extensors, pressure points- psoriasis
 Scalp, nasolabial folds, flexors- seborrhic dermatitis
 Photo exposed parts- photosensitivity

10. Past History
- Any medication received recently should be
noted, including regular or intermittent self medication.
-Any past illness (medical, surgical) and therapy,
thereof, are important in drug eruptions.
- History of medical disorders like diabetes,
hypertension, tuberculosis, seizures etc
-The dermatosis could be a manifestation of the
disease or could be an adverse effect of the drug
used to treat the disease.
-Past exposure to Mycobacterium tuberculosis
is important, when cutaneous tuberculosis is
suspected.

11.  Family History
 Family history is important in patients with:
 Genetic disorders like ichthiosis, neurofibromatosis
and epidermolysis bullosa.
 Infections and infestations, e.g., scabies, pediculosis.
 Families who are exposed to similar environmental
influences may also develop same problems e.g.,
arsenical keratoses.

12.  Other History
 Social, occupational, travel and recreational history
may help the physician in reaching a diagnosis.

13. ERUPTIONS description and
terminology
 Macules- not raised above the skin(less then 0.5 cm)
Patches- not raised above the skin- more than 0.5 cm
 Papules- raised tiny eruption felt on skin( less than 0.5 cm)
 Nodules- raised, firm eruption more than 0.5 cm
 Tumour- raised, firm eruption more than 5 cm
 Vesicles- an elevated horny layer of the epidermis by collection of
transparent or milky fluid within it which is less than 0.5 cm in size
Eg. Chicken pox, herpes zoster, small-pox
Bulla- more than 0.5 cm
 Pustules- vesicles contain pus

14.  Plaque- a larged,>1 cm , flat topped, raised lesion
which is indurated
 Wheal- a raised erythematous , oedematous eruption
due to short lived vasodilatation and vasopermeability
 Telangiactasis- a dilated superficial blood vessel

15. Macules
Macule is a circumscribed, flat lesion of skin,
which is visible because of a change in skin
Color .
> Not felt, as no change in skin texture.
> Macules may be well-defined or ill-defined and
may be of any size.
> A macule may be: Hyperpigmenteor or hypopigmented
eg., fixed drug eruption, caféau lait macule .
>Hyperpigmented macules may be Brown, if the melanin
pigment is present in the epidermis, e.g., café au lait
macule.

18.  Slate gray or violaceous, if melanin is
present in dermis e.g.Mongolian spot.
 Brownish grey, if melanin is present both
in the epidermis and dermis, e.g., nevus of
Ota (some patients).
 Hypopigmented: when the lesion is less pigmented
than the surrounding skin, e.g., leprosy.
 If the lesion is completely devoid of
pigment it is labelled as depigmented, e.g,
vitiligo , piebaldism.

19. papules
 Small, solid, elevated lesion, <0.5 cm in diameter
(Fig. 2.3). A major portion of the papule projects above the
skin.
 Papules can be due to:
 Hyperplasia of cellular components of epidermis
or dermis.
 Metabolic deposits in dermis.
 Cellular infiltrate in dermis.
 Papules may be surmounted by scales or crusts
and may evolve into vesicles and pustules.

20. Papules

22. Tumors
 Tumors
Tumor implies enlargement of tissues, by
normal or pathological material or cells, to
form a mass

23. Plaques
An area of altered consistency of skin which
is usually elevated, but can be depressed or
flushed with surrounding skin.
Are formed either by enlargement of individual
papules or their confluence.
Plaques may be discoid (uniformly
thickened) or annular (ring shaped). Annular
plaques can form either when center of a
discoid plaque clears or due to confluence of
papules.

24.  Excoriation- linear angular erosion that may be
covered by crust and are caused by scratching
 Atrophy- an aquired loss of substance( loss of dermal
or subcutaneus tissue with intact epidermis) or shiny,
delicate, wrinkled lesion(epidermal atrophy)
 Scar- a change in skin secondary to trauma or
inflammation or surgery

25. lichenification

27. Crust

28. vesicles

29. pustules

30. Abscess

31. urticarea

32. Dermographic urticarea

33. Telengiactasis- dilated blood
vessals

34. lichenification

35. Burrow: Is pathognomonic lesion of scabies.
Appears as a serpentine, thread-like, grayish (or
darker) curvilinear lesion, varying in length from
a few millimeters to a centimeter.
The open end is marked by a papule. The burrow
may be difficult to discern in dark-skinned
individuals.
Comedones: Comedones are inspissated
plugs of keratin and sebum wedged in dilated
pilosebaceous orifices. Comedones are typically

36. present in acne vulgaris, in nevus comedonicus
and in senile comedones. There are two types
of comedones:
Open comedone: black head, in which the
keratinous plug is black
Closed comedone: white head, in which the
plug is covered by skin, so the lesion appears
as a white shiny papule

37. Black heads, comedones

38. Comedones- white

39. Scabies - burrow

40. Sinus

41.  Cyst – a soft , raised cencapsulated lesion filled with
semisolid or liquid contents
 Herpetiform- grouped lesion
 Lichenoid- violaceous to purple , polygonal lesion seen
in lichen planus
 Milia- small firm,while papule filled with keratin
 Morbilliform- generalized , small erythematous
macules, papules seen in measles
 Nummular coin shaped eruption
 Polycyclic- a configuration of lesion formed from
coalescing ring or incomplete rings.

42. pattern
 Linear
 Annular
 Grouped
 Reticular
 Spider
 Arciform( arc like)

43. Haemorrhage causind skin
changes
 Petechiae- Tiny less than 1mm in diameter.
 Purpura- 2-5 mm in diameter
 Echymosis- more than 5 mm in diameter
 Hematoma-haemorrhage large enough to produce elevation of the
skin.
 Causes-Deficiency-scurvy
Infection-meningococcal meningitis
bacterial endocarditis
Haematological- leukemia
thrombocytopenia
aplastic anemia

44. examination
Environment for Examination
Examine patients in natural lighting. Oblique
lighting may be necessary to detect subtle elevation
of lesions, while subdued lighting enhances
subtle changes in pigmentation.
Expose the area affected and do not hesitate
to ask the patient to undress if need be (in
the presence of an attendant, if required). Do
not let stubbornness, shyness or the sex of the
patient put you off!
Remove make-up if necessary.
Magnification: An ordinary magnifying glass
(5×, 10×) can provide much needed information.

45. Examination
 Skin lesions have to be described in three terms:
 Morphology – macules, papules etc
 Distribution.
 Configuration.
 Also always remember to examine nails, hair (and
scalp) and mucosae (oral, genital and nasal).

46.  Look for the colour, pigmentation, hypo pigmentation, eruptions,
haemorrhage etc.
 Colour- It may be pale, flushed, cyanosed or yellow.
 Hypo pigmentation- leprosy
- leucoderma
- Albinism
- Tinea versicolar

47. vitiligo

48. Tinea versicolor

49. Measles-macular eruption

50. Folliculitis – maculo-papuiar
eruption

51. Herpes zoster-vesicular
eruption

52. Herpes labialis

53. Plant rash
 Plant rash
 Vesicular eruption

54. Bulla

55. Eczema

56. Erythema multiforme

57. Erythema infectiosum

58. Warts

59. psoriasis

60. MOLES

61. urticarea

62. leprosy

63. Petechiae and purpura

66. Echymosis

67. Echymosis

68. HAIRS
 Falling of hairs- Anemia
Infection
 Patchy hair loss- Alopecia areata,
Syphilis
Tinea capites
 Loss of outer third of the eyebrow- Leprosy
Myxoedema
 Absence of axillary, pubic and facial hair-
Hypopitutarisum
Hypogonadism
 Excess of body hair growth in women-
Adrenocortical syndrome
Cushing syndrome

69. Alopecia areata

70. Alopecia areata

71. Alopecia universalis

72. Tinea capites

73. Tinea capites

74. leprosy

75. Nails
 Pallor
 Koilonychias- spoon shaped nail due to iron deficiency
anemia
 Onychia- deformity of nails due to fungal infection
 Discoloration- due to Reynaud's disease, mercury and
silver poisoning
 Clubbing
 Haemorrhages- sub acute bacterial endocarditic,
bleeding disorder, injury.
 Trophic changes- ribbing, brittleness, falling of nail
occurs in syringomyelia, leprosy, tabes dorsalis.

76. Investigation
 Tzanck smear- a fresh bulla is chosen and cleaned
with spirit. The bullae is derooofed and its contents
are drained. The base of the blister is scraped with the
blunt edge of the sterile sergical blade and contents
are shifted on sterile glass slide.smea is prepared in
circular motion along one direction which is dried and
heat fixed. It is then stained with Geimsa stain. The
slide is then examined undere emersion field.
Acantholytic cells are seen in pemphigus, herpes
zoster, chicken pox etc
Wood lamp-produces long wave UVL
Tinea versicolor/ tinea capitis- yellow green
Vitiligo-milky white

77.  skin biopsy – it can be carried out by taking a tiny bit-
0.4mm to 0.6 mm of affected part. Specimen is
transferred to formalin for sectioning and staining.
 Fungal scraping- dermatophytes or yeast are scraped
with the help of clean ,sterile blade from margin of
lesion. The content are transferred to a drop of 10%
KOH kept on sterile glass slide. Nail are also soaked
overnight in 20% KOH before microscopic
examination. Fungal hair infection can be tested inb
same mannere.

78.  Slit- smear examination- useful in case of M leprae
infection. Prepared from ear lobes, eyebrows or from
skin lesions. The area is gently scraped from the
margin of the blade after cleansing with spirit. It is air
dried and heat fixed and then stained with Z-N stain. It
is examined under the oil emersion lens for
microbacteria.

79.  Diascopy- a clean glass slide which is used for light
microscopy is taken and pressed up on lesion.
 Useful for- lupus vulgaris, granuloma annulare will
show apple jelly nodules which appear brownish
yellow to golden in hue.
 Also in psoriasis to visualise Auspitz’s sign.

80.  Dermatoscopy- useful to examine pigmented moles,
skin neoplasm, hair disorders, haemangioma etc.