2. CONTENTS
1. CLINICAL EXAMINATION IN SKIN DISEASE
2. TERMS USED TO DESCRIBE SKIN LESIONS
3. HAIR DISORDERS
4. COMMON NAIL CHANGES AND DISORDERS
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3. CLINICAL EXAMINATION IN
SKIN DISEASE
Observation:
The patient must be undressed, with make-up and
dressings removed, and examined in good lighting.
Consider the following:
• Age
• General health
• Distress
• Scratching
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4. 1. Distribution of rash
Symmetrical vs asymmetrical
Proximal vs distal vs facial
Localised vs widespread
2. If symmetrical
Extensor, e.g. psoriasis
Flexor, e.g. eczema
3. Nail involvement
Psoriatic changes in nails and peri-ungual involvement
4. Involvement of hands:
including nail folds
and finger webs
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5. 5. Involvement of axillae/groin
e.g. hidradenitis suppurativa
6. Individual lesions
Discrete, grouped, confluent,
reticulate (lace-like), linear
7. Morphology of rash
Monomorphic or polymorphic
8. Morphology of individual lesions
Use a hand lens in good lighting to assist
Use correct terminology
e.g. macules, papules, pustules
Palmoplantar pustulosis
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6. 9. Examination of scalp
Hair loss
Scalp changes
10. Involvement of face
Central
Hairline
Cheeks and nasal bridge:
‘butterfly’ distribution
Sparing of light-protected sites, e.g. behind ears, under chin
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7. 11. Eye involvement
e.g. Conjunctivitis/blepharitis in rosacea or eyelash loss in
alopecia areata
12. Oral and genital involvement
Reticulate (lacy) network on buccal mucosa in lichen planus.
May also be genital involvement
13. Joint involvement
e.g. Psoriatic arthritis
14. General medical examination
Including lymph nodes and other systems as indicated
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8. TERMS USED TO DESCRIBE
SKIN LESIONS
Macule A circumscribed flat area of altered colour, ≤ 1
cm diameter
Patch As for macule, but larger
Papule A discrete elevation of skin
Nodule As for papule, but > 1 cm diameter and involving
dermis
Plaque A raised area of skin with a flat top, > 1 cm
across
Excoriation A linear ulcer or erosion resulting from
scratching
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9. TERMS USED TO DESCRIBE
SKIN LESIONS
Vesicle/bulla A small (≤ 1 cm)/larger (> 1 cm) blister,
respectively
Pustule A visible accumulation of pus in a blister
Abscess A localised collection of pus in a cavity
Weal An evanescent discrete area of dermal oedema
Scale A flake arising from the stratum corneum
Crust Dried exudate of blood or serous fluid
Ulcer An area from which the epidermis and the upper
dermis have been lost
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10. TERMS USED TO DESCRIBE
SKIN LESIONS
Petechiae, purpura, ecchymosis
Petechiae are flat, pinhead-sized macules of
extravascular blood in the dermis; larger ones (purpura)
may be palpable; deeper bleeding causes ecchymosis
Burrow A linear or curvilinear papule, caused by a
burrowing
scabies mite
Comedone A plug of keratin and sebum in a dilated
pilosebaceous orifice
Telangiectasia Visible dilatation of small cutaneous blood
vessels
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11. TERMS USED TO DESCRIBE
SKIN LESIONS
Erosion An area of skin denuded by complete or
partial loss of the epidermis
Fissure A deep, slit-shaped ulcer, e.g. irritant
dermatitis of the hands
Sinus A cavity or channel that permits the escape of
pus or fluid
Scar Permanent fibrous tissue resulting from healing
Atrophy Loss of substance due to diminution of the
epidermis, dermis or subcutaneous fat
Stria A linear, atrophic, pink/purple/white lesion in
the connective tissue
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12. HAIR DISORDERS
Alopecia
The term means nothing more than loss
of hair and is a sign rather than a
diagnosis.
It is subdivided into localised or diffuse
types and also into scarring or non-
scarring alopecia.
1. Alopecia areata
2. Androgenetic alopecia
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13. 1. ALOPECIA AREATA
This common, non-scarring autoimmune condition
appears as well-defined, non-inflamed bald patches,
usually on the scalp.
Pathognomonic ‘exclamation mark’ hairs are seen
(brokenoff hairs 3–4 mm long, tapering towards the
scalp) during active hair loss.
The condition may affect the eyebrows, eyelashes and
beard.
The hair usually regrows spontaneously in small bald
patches, but the outlook is less good with larger patches
and when the alopecia appears early in life or is
associated with atopy.
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14. 2. ANDROGENETIC ALOPECIA
Male-pattern baldness is physiological in men > 20 yrs
old, although rarely it may be extensive and develop at
an alarming pace in the late teens.
It also occurs in females, most obviously after the
menopause.
The distribution is of bitemporal recession and then
crown involvement.
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16. 1. EFFECTS OF TRAUMA
1. Nail biting/picking:
These are very common.
Repetitive proximal nail-fold trauma results in
transverse ridging and central furrowing of the nail.
2. Chronic trauma:
Trauma from poorly fitting shoes and sport can cause
thickening, disordered nail growth (onychogryphosis)
and subsequent ingrowing toenails.
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17. 3. Splinter haemorrhages:
Fine, linear, dark brown longitudinal streaks in the plate are
usually caused by trauma, especially if distal.
Uncommonly, they can occur in nail psoriasis and are a hallmark
of infective endocarditis.
4. Subungual haematoma:
Red, purple or grey–brown discoloration of the nail plate, usually
of the big toe, is usually due to trauma, although a history of
trauma may not be clear.
The main differential is subungual melanoma, although rapid
onset, lack of nail-fold involvement and proximal clearing as the
nail grows are clues to the diagnosis of haematoma.
If there is diagnostic doubt, a biopsy may be needed.
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18. 2. NAIL IN SYSTEMIC DISEASE
1. Beau’s lines:
These transverse grooves appear at the same time on
all nails, a few weeks after an acute illness, moving
out to the free margins as the nails grow.
2. Koilonychia:
This concave or spoon-shaped deformity of the plate is a
sign of iron deficiency.
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19. 3. Clubbing:
In its most gross form, this is seen as a bulbous swelling
of the tip of the finger or toe.
The normal angle between the proximal part of the nail
and the skin is lost.
Causes include:
● Respiratory: bronchogenic carcinoma, asbestosis,
suppurative lung disease (empyema, bronchiectasis,
cystic fibrosis), idiopathic pulmonary fibrosis.
● Cardiac: cyanotic congenital heart disease, subacute
bacterial endocarditis.
● Other: inflammatory bowel disease, biliary cirrhosis,
thyrotoxicosis, familial causes.
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20. 4. Discoloration of the nails:
Whitening is a rare sign of hypoalbuminaemia.
‘Half and half’ nails (white proximally and red-brown
distally) occur occasionally in patients with renal failure.
Rarely, drugs (e.g. antimalarials) may discolour nails
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