Skin complaints are common in clinical exams and everyday practices. Skin cancers are increasing in prevalence and if detected early, treatment can be curative. cutaneous signs can also be a vital in identifying systemic diseases. With a structured examination technique and a little knowledge of terminology, skin signs can classified systematically.

2. THE SKIN HISTORY
1) CHIEF COMPLAINT
2) HISTORY OF PRESENT ILLNESS
(onset,course,intermittent or contagious-always present
or does it come and go)?
3) PAST MEDICAL HISTORY- medications,allergies.
4) FAMILY HISTORY-psoriasis, infestations,infections.
5) PSYCHO-SOCIAL HISTORY–personal
habits,exposures,health-related behaviours.
6) SOCIALHISTORY-occupation
7) REVIEW OF SYSTEMS-involves performing a brief
screen for symptoms in other body systems.

3. Q1- When did it start?
Q2-Does it itch,burn or hurt?
Q3-Associated symptoms?
Q4-Is this the first episode?
Q5-Where on the body did it start (location)?
Q6-How has it spread ?
Q7-How have individual lesions changed?
Q8-Provoking /aggravating factors?
Q9-Previous treatments and response?

4. EXAMINATION AIDES /ESSENTIAL
ELEMENTS FOR THE SKIN EXAM
• Ruler :-> Accurately records the size of a lesion on
successive examination.
• Lighting
• Pen light
• Gloves
• Magnifying glass
• Woods lamp :->(long wavelength U.V light) to
examine if a lesion is hypo or depigmented or to
see if a fungal infection fluoresces.

5. • Dermatoscopes :-> Magnify the lesions with a hand
lens or using epiluminescence microscopy ( using a
hand lens with magnification & lighting built into
better visualize lesions.
• Avoid LED lights.
• Penlight :->
Is used for slide lighting.
Detects atrophy & fine wrinkling
Distinguishes flat from raised lesions whether lesions
are solid or fluid filed.
• Diascopy :-> Press a transparent firm object such as a
glass slide against a lesion to determine if an
erythematous lesion blanches (loses red
color),lesions remains red suggests – purpura.

6. DIASCOPY

7. WOOD’S LAMP

8. THE TOTAL BODY SKIN EXAM INCLUDES
INSPECTION OF THE ENTIRE SKIN
SURFACE INCLUDING-
o The scalp ,hair,and nails
o The mucous membranes of the mouth ,eyes ,anus and
genitals.
 HISTORY OF HAIRS AND NAILS-
 Timing of onset
 Associated symptoms
 Nutritions- iron deficiency (spoon nails),zinc
deficiency(beau’s lines)
 elevating /Aggravating
 Treatments
 Exposures

9. EXAMINATION
• Inspection :->
Colour i.e dark purple(purpura)
Distribution( symmetry)-suggesting a external cause
i.e. Infection,trauma etc.
Do lesions leave pigment change (increased or
decreased) or scars?
Shape and size
Border
o Well demarcated or indistinct.
o Ask the patient to indicate early and late lesions
o Decide what is primary or secondary & how lesions
evolves or spread.
Any particular pattern –diffuse,linear,grouped or
scattered.

10. COLOR TYPES IN DIFFERENT LESIONS
1) RED SKIN – erythema ,cutaneous tumors
2) ORANGE SKIN- hypercarotenemia
3) YELLOW SKIN – jaundice,xanthelasmas and xanthomas
and pseudoxanthoma elasticum.
4) GREEN FINGERNAILS- pseudomonas aeruginosa infection.
5) VIOLET SKIN – cutaneous hemorrhage or vasculities. A
LILIAC color of the eyelids is characteristics of
dermatomyositis.
6) SHADES OF BLUE,SILVER AND GRAY- from deposition of
drugs ormetals in skin.Ischemic skin appears purple to
gray in color.
7) BLACK SKIN- malenoma,or by infections i.e.
meningococcemia .

11. Specifies of rash description----
 Excoriation-
o Look for linear scratch works (excoriations) indicative of
itching (pruritus)
 Ulcer/erosion-
o Is the skin eroded (involves epidermis and heals without
a scar) or ulcerated (extendes upto dermis and heals
with scaring)?
 Weeping –if something is oozing out from the lesion.
 Crusting (when serum,blood,pus dries on skin surface) ,
Scale, hyperkeratosis.
 Blood vessels -
o Suggesting skin atrophy or superficial vasculature
 Odour-
o Foul smelling ulcers may be infected with anaerobes or
pseudomonas aeruginosa some rashes smell unplesant
Ex. Darier disease.

12.  PALPATION--Tenderness
-In the elderly people,patients taking systemic steroids or patients with rheumatoid
arthritis ,the skin may exceptionally fragile.
 SURFACE TEXTURE-The surface texture of lesions can be assessed by running a finger over the
top of a lesion to feel if the skin is smooth or rough.
 SCALING -If scaling is not easily visible,lightly scraps a lesion with your fingernail scaling.
 ELEVATION-Palpable/flat.
 If SKIN IS RED –check blanching with light pressure.
-purpura (non blanching) is caused by leakage of blood into the
perivascular dermal tissues.
 SKIN THICKNESS AND DEPTH OF INVOLVEMENT –ATROPHY (
TISSUE LOSS) WITH WRINKLING OR DIMPLING (LOSS OF FAT)
 TETHERING- Gently pinch the skin or try to pick up lumps between finger and
thumb to assess depth .Is there any tethering to lying tissue?
 CHECK FOR ASSOCIATED SIGNS –
 FEEL TEMPERATURE
-INFLAMED SKIN
-CELLULITIS –HOT
-POORLY PERFUSED-COLD SKIN
 MOBILITY

13. oSEQUENCE-
o REGIONAL
o SYSTEM
THREE CATEGORIES OF OBSERVATION-
1. Anatomic distribution of the
lesion.(location on body)
2. Configuration of groups of lesions.(how
lesions are arranged or related to each
other)
3. The morphology of individual lesions.

17. DIAGNOSTIC METHODS
BIOPSY
LABORATORY STUDIES

18. Primary skin lesions
1.MACULE 7.BULLA
13.ECHYMOSIS
2.PAPULE 8.POSTULE 14-
HEMATOMA
3.PLAQUE 9.WHEAL
15.POIKILODERMA
4.NODULE 10.TELANGICTASIA 16-
ERYTHEMA
5.PAPILLOMA 11.PETECHIAE 17-
BURROW
6.VESICLE 12.PURPURA 18-

21. EXAMPLES OF DIFFERENT SKIN
LESIONS
1. MACULES- freckles (small brown spots on skin),flat
moles,tattoos,and the rashes of rickettsial
infections,rubella,measles(can also have pustules and plaques)
and some allergic drug eruptions.
2. PAPULES-warts,some lesions of acne,skin cancer,lichen
planus,actinic keratoses(due to sun exposure).
3. PLAQUES- psoriasis and granuloma annulare.
4. NODULES- cysts,lipomas and fibromas.
5. VESICLES- herpes infection,acute allergic contact dermatitis and
some autoimmune blistering disorders (e.g. Dermatities
herpetiformis)
6. BULLAE- burns ,bites,allergic contact dermatities and durg
reaction.
7. PUSTULES- In Bacterial infections ,pustular psorasis,folliculitis.

22. Rapid Evolution In Chickenpox

23. Dengue fever rash

24. Urticaria

25. Pustule

26. Bullae

28. Psoriasis Plaque

29. Papule

30. Labial melanotic macule

34. SECONDARY SKIN LESIONS
• 1-SCALE 7-ULCER
• 2-CRUST 8-SINUS
• 3-EXCORIATION 9-SCAR
• 4-LICHENIFICATION 10-KELOID
• 5-FISSURE 11-ATROPHY
• 6-EROSION 12-STRIA

36. PRIMARY AND SECONDARY LEISONS

37. IDENTIFYING PRIMARY AND
SECONDARY SKIN LESION
 PRIMARY LESIONS-
I. BULLA- a vesicles greater than 5 mm in diameter.
II. CYST-An elevated ,circumscribed area of the skin filled with liquid or semisolid fluid.
III. MACULE-a flat,circumscribed area;can be brown ,red,white or tan.
IV. NODULE-an elevated,firm,circumscribed,and palpable area greater than 5mm in diameter,can
involve all skin layers.
V. PAPULE- an elevated,palpable,firm,circumscribed area generally less than 5mm in diamter.
VI. PLAQUE- an elevated ,flat-topped,firm,rough,superficial papule greater than 2cm in diameter;
VII. VESICLE-an elevated ,circumscribed,superficial,fluid-filled blister less than 5mm in diameter
VIII. WHEAL-an elevated,irregular shaped area of cutaneous edema;wheals are solid,transient,and
changeable,with a variable diameter;can be red,pale pink,white.
IX. purpura- a rash of purple spots due to leakage of blood from small blood vessels.
X. PETECHIAE-tiny round ,brown purple spots due to bleeding under the skin ,may be in small
area or widespread.
XI. ECCHYMOSIS- a flat ,blue or purple patch measuring 1cm in diameter.

38. SECONDARY LESIONS
1. CRUST-A slightly elevated area of variable
size;consists of dried serum,blood, or purulent
exudate.
2. EXCORIATION- linear scratches that may or may
not be denuded.
3. LICHENIFICATION- rough,thickened
epidermis;accentuated skin markings caused by
rubbing or scratching.
4. SCALE-heaped-up keratinized cells;thick or
thin;dry or oily;variable size,can be white or tan.

40. HYPERPIGMENTED MACULES

41. THREE HYPOPIGMENTED MACULES ON LOWER BACK

42. PURPURA

43. INFANT WITH ECCHYMOSES

44. VESICLES

45. VESICLES

47. DIAGNOSIS AND
MANAGEMENT OF TVAK
VIKARAS IN AYURVEDA
• Diagnosis of tvak roga
 Based on the clinical features.
 Based on the Dosha involved.
 Examination of the lesions.
 Complete History of illness
 Past history
 Svatantra and paratantra (eczema due to vericose
veins)

48. PHYSICAL EXAMINATION OF
THE SKIN
 A. Initial clinical Impression – Does the patient look ill,i.e.
Anxious,calm,angry etc.
 B.Complete skin Examination (4 components)-HEAD TO TOE
EXAMINATION
o Skin
o Hair
o Nails
o Mucous membranes
 C.Cardinal features of examination (4 Cardinal features)-
1 . Type of Lesion-primary vs secondary
2. Shape of lesion
3. Arrangement of lesions]
4. Distribution of lesions
 D.Characteristics of individual lesions

49. CLINICAL FEATURES
• Vata Pradhana Pith Pradhana KaphaPradhana
 Parushya Daha shvetata
 Shosha Raga Saityata
 Toda paka kandu
 Shoola visragandha sthairya
 Sankocha kleda utseda
 Ayama angapatana gourava
 Harsh sneha
 Shyava-arunatva kleda
 jantubhiabhibhakshana