Approach to the Patient with a Skin Disorder

 

 

Approach to the Patient with a Skin Disorder

Thomas J. Lawley

Kim B. Yancey

The challenge of examining the skin lies in distinguishing normal from abnormal, significant findings from trivial ones, and in integrating pertinent signs and symptoms into an appropriate differential diagnosis. The fact that the largest organ in the body is visible is both an advantage and a disadvantage to those who examine it. It is advantageous because no special instrumentation is necessary and because the skin can be biopsied with little morbidity. However, the casual observer can be misled by a variety of stimuli and overlook important, subtle signs of skin or systemic disease. For instance, the sometimes minor differences in color and shape that distinguish a malignant melanoma  from a benign pigmented nevus  can be difficult to recognize. To aid in the interpretation of skin lesions, a variety of descriptive terms have been developed to characterize cutaneous lesions and to formulate a differential diagnosis (Table 3).

For instance, the finding of large numbers of scaling papules, usually indicative of a primary skin disease, places the patient in a different diagnostic category than would hemorrhagic papules, which may indicate vasculitis or sepsis . It is important to differentiate primary skin lesions from secondary skin changes. If the examiner focuses on linear erosions overlying an area of erythema and scaling, he or she may incorrectly assume that the erosion is the primary lesion and the redness and scale are secondary, while the correct interpretation would be that the patient has a pruritic eczematous dermatitis with erosions caused by scratching.

 

 

TABLE 1 Descriptions of Primary Skin Lesions

Macule: A flat, colored lesion, <2 cm in diameter, not raised above the surface of the surrounding skin. A “freckle,” or ephelid, is a prototype pigmented macule. Patch: A large (>2 cm), flat lesion with a color different from the surrounding skin. This differs from a macule only in size. Papule: A small, solid lesion, <0.5 cm in diameter, raised above the surface of the surrounding skin and hence palpable (e.g., a closed comedone, or whitehead, in acne). Nodule: A larger (0.5–5.0 cm), firm lesion raised above the surface of the surrounding skin. This differs from a papule only in size (e.g., dermal nevus). Tumor: A solid, raised growth >5 cm in diameter. Plaque: A large (>1 cm), flat-topped, raised lesion; edges may either be distinct (e.g., in psoriasis) or gradually blend with surrounding skin (e.g., in eczematous dermatitis). Vesicle: A small, fluid-filled lesion, <0.5 cm in diameter, raised above the plane of surrounding skin. Fluid is often visible, and the lesions are often translucent [e.g., vesicles in allergic contact dermatitis caused by Toxicodendron (poison ivy)]. Pustule: A vesicle filled with leukocytes. Note: The presence of pustules does not necessarily signify the existence of an infection. Bulla: A fluid-filled, raised, often translucent lesion >0.5 cm in diameter. Cyst: A soft, raised, encapsulated lesion filled with semisolid or liquid contents. Wheal: A raised, erythematous papule or plaque, usually representing short-lived dermal edema. Telangiectasia: Dilated, superficial blood vessels.

TABLE 2 Common Dermatologic Terms

Lichenification: A distinctive thickening of the skin that is characterized by accentuated skin-fold markings and that feels thick on palpation. Crust: Dried exudate of body fluids that may be either yellow (serous exudate) or red (hemorrhagic exudate). Milia: Small, firm, white papules that are filled with keratin (and may in part resemble pustules). Erosion: Loss of epidermis without an associated loss of dermis. Ulcer: Loss of epidermis and at least a portion of the underlying dermis. Excoriations: Linear, angular erosions that may be covered by crust and are caused by scratching. Atrophy: An acquired loss of substance. In the skin, this may appear as a depression with intact epidermis (i.e., loss of dermal or subcutaneous tissue) or as sites of shiny, delicate, wrinkled lesions (i.e., epidermal atrophy). Scar: A change in the skin secondary to trauma or inflammation. Sites may be erythematous, hypopigmented, or hypertrophic depending on their age or character. Sites on hair-bearing areas may be characterized by destruction of hair follicles. Pruritus: A sensation that elicits the desire to scratch. Pruritus is often the predominant symptom of inflammatory skin diseases (e.g., atopic dermatitis, allergic contact dermatitis); it is also commonly associated with xerosis and aged skin. Systemic conditions that can be associated with pruritus include chronic renal disease, cholestasis, pregnancy, malignancy, polycythemia vera, and delusions of parasitosis.

 

TABLE 3 Selected Common Dermatologic Conditions

Diagnosis Common Distribution Usual Morphology   Acne vulgaris Face, upper back Open and closed comedones, erythematous papules, pustules, cysts Rosacea Blush area of cheeks, nose, forehead, chin Erythema, telangiectasias, papules, pustules Seborrheic dermatitis Scalp, eyebrows, perinasal areas Erythema with greasy yellow-brown scale Atopic dermatitis Antecubital and popliteal fossae; may be widespread Patches and plaques of erythema, scaling, and lichenification; pruritus Stasis dermatitis Ankles, lower legs Patches of erythema and scaling on background of hyperpigmentation associated with signs of venous insufficiency Dyshidrotic eczema Palms, soles, sides of fingers and toes Deep vesicles Allergic contact dermatitis Anywhere Localized erythema, vesicles, scale, and pruritus (e.g., fingers, earlobes—nickel; dorsal aspect of foot—shoe; exposed surfaces—poison ivy) Psoriasis Elbows, knees, scalp, lower back, fingernails (may be generalized) Papules and plaques covered with silvery scale; nails have pits Lichen planus Wrists, ankles, mouth (may be widespread) Violaceous flat-topped papules and plaques Keratosis pilaris Extensor surfaces of arms and thighs, buttocks Keratotic follicular papules with surrounding erythema Melasma Forehead, cheeks, temples, upper lip Tan to brown patches Vitiligo Periorificial, trunk, extensor surfaces of extremities, flexor wrists, axillae Chalk-white macules Actinic keratosis Sun-exposed areas Skin-colored or red-brown macule or papule with dry, rough, adherent scale Basal cell carcinoma Face Papule with pearly, telangiectatic border on sun-damaged skin Squamous cell carcinoma Face, especially lower lip, ears Indurated and possibly hyperkeratotic lesions often showing ulceration and/or crusting Seborrheic keratosis Trunk, face Brown plaques with adherent, greasy scale; “stuck on” appearance Folliculitis Any hair-bearing area Follicular pustules Impetigo Anywhere Papules, vesicles, pustules, often with honey-colored crusts Herpes simplex Lips, genitalia Grouped vesicles progressing to crusted erosions Herpes zoster Dermatomal, usually trunk but may be anywhere Vesicles limited to a dermatome (often painful) Varicella Face, trunk, relative sparing of extremities Lesions arise in crops and quickly progress from erythematous macules to papules to vesicles to pustules to crusts Pityriasis rosea Trunk (Christmas tree pattern); herald patch followed by multiple smaller lesions Symmetric erythematous patches with a collarette of scale Tinea versicolor Chest, back, abdomen, proximal extremities Scaly hyper- or hypopigmented macules Candidiasis Groin, beneath breasts, vagina, oral cavity Erythematous macerated areas with satellite pustules; white, friable patches on mucous membranes Dermatophytosis Feet, groin, beard, or scalp Varies with site, (e.g., tinea corporis—scaly annular patch) Scabies Groin, axillae, between fingers and toes, beneath breasts Excoriated papules, burrows, pruritus Insect bites Anywhere Erythematous papules with central puncta Cherry angioma Trunk Red, blood-filled papules Keloid Anywhere (site of previous injury) Firm tumor, pink, purple, or brown Dermatofibroma Anywhere Firm red to brown nodule that shows dimpling of overlying skin with lateral compression Acrochordons (skin tags) Groin, axilla, neck Fleshy papules Urticaria Anywhere Wheals, sometimes with surrounding flare; pruritus Transient acantholytic dermatosis Trunk, especially anterior chest Erythematous papules Xerosis Extensor extremities, especially legs Dry, erythematous, scaling patches; pruritus

 

APPROACH TO THE PATIENT

In examining the skin it is usually advisable to assess the patient before taking an extensive history. This way, the entire cutaneous surface is sure to be evaluated, and objective findings can be integrated with relevant historic data. Four basic features of any cutaneous lesion must be noted and considered in the examination of

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skin: the distribution of the eruption, the type(s) of primary lesion, the shape of individual lesions, and the arrangement of the lesions. In the initial examination it is important that the patient be disrobed as completely as possible. This will minimize chances of missing important individual skin lesions and make it possible to assess the distribution of the eruption accurately. The patient should first be viewed from a distance of about 1.5 to 2 m (4 to 6 ft) so that the general character of the skin and the distribution of lesions can be evaluated. Indeed, distribution of lesions often correlates highly with diagnosis . For example, a hospitalized patient with a generalized erythematous exanthem is more likely to have a drug eruption than is a patient with a similar rash limited to the sun-exposed portions of the face. The presence or absence of lesions on mucosal surfaces should also be determined. Once the distribution of the lesions has been established, the nature of the primary lesion must be determined. Thus, when lesions are distributed on elbows, knees, and scalp, the most likely possibility based solely on distribution is psoriasis or dermatitis herpetiformis The primary lesion in psoriasis is a scaly papule that soon forms erythematous plaques covered with a white scale, whereas that of dermatitis herpetiformis is an urticarial papule that quickly becomes a small vesicle. In this manner, identification of the primary lesion directs the examiner toward the proper diagnosis. Secondary changes in skin can also be quite helpful. For example, scale represents excessive epidermis, while crust is the result of a discontinuous epithelial cell layer. Palpation of skin lesions can also yield insight into the character of an eruption. Thus red papules on the lower extremities that blanch with pressure can be a manifestation of many different diseases, but hemorrhagic red papules that do not blanch with pressure indicate palpable purpura characteristic of necrotizing vasculitis

The shape of lesions is also an important feature. Flat, round, erythematous papules and plaques are common in many cutaneous diseases. However, target-shaped lesions that consist in part of erythematous plaques are specific for erythema multiforme In the same way, the arrangement of individual lesions is important. Erythematous papules and vesicles can occur in many conditions, but their arrangement in a specific linear array suggests an external etiology such as allergic contact

irritant dermatitis. In contrast, lesions with a generalized arrangement are common and suggest a systemic etiology.

As in other branches of medicine, a complete history should be obtained to emphasize the following features:

• Evolution of lesions
• Site of onset
• Manner in which the eruption progressed or spread
• Duration
• Periods of resolution or improvement in chronic eruptions
• Symptoms associated with the eruption
• Itching, burning, pain, numbness
• What, if anything, has relieved symptoms
• Time of day when symptoms are most severe
• Current or recent medications (prescribed as well as over-the-counter)
• Associated systemic symptoms (e.g., malaise, fever, arthralgias)
• Ongoing or previous illnesses
• History of allergies
• Presence of photosensitivity
• Review of systems

DIAGNOSTIC TECHNIQUES

Many skin diseases can be diagnosed on gross clinical appearance, but sometimes relatively simple diagnostic procedures can yield valuable information. In most instances, they can be performed at the bedside with a minimum of equipment.

Skin Biopsy

A skin biopsy is a straightforward minor surgical procedure; however, it is important to biopsy a lesion that is most likely to yield diagnostic findings. This decision may require expertise in skin diseases and knowledge of superficial anatomic structures in selected areas of the body. In this procedure, a small area of skin is anesthetized with 1% lidocaine with or without epinephrine. The skin lesion in question can be excised with a scalpel or removed by punch biopsy. In the latter technique, a punch is pressed against the surface of the skin and rotated with downward pressure until it penetrates to the subcutaneous tissue. The circular biopsy is then lifted with forceps, and the bottom is cut with iris scissors. Biopsy sites may or may not need suture closure, depending on size and location.

KOH Preparation

A potassium hydroxide (KOH) preparation is performed on scaling skin lesions where a fungal etiology is a possibility. The edge of such a lesion is scraped gently with a scalpel blade, and the removed scale is collected on a glass microscope slide and treated with 1 to 2 drops of a solution of 10 to 20% KOH. KOH dissolves keratin and allows easier visualization of fungal elements. Brief heating of the slide accelerates dissolution of keratin. When the preparation is viewed under the microscope, the refractile hyphae will be seen more easily when the light intensity is reduced and the condenser is lowered. This technique can be utilized to identify hyphae in dermatophyte infections pseudohyphae and budding yeast in Candida infections and fragmented hyphae and spores in tinea versicolor. The same sampling technique can be used to obtain scale for culture of selected pathogenic organisms.

Tzanck Smear

A Tzanck smear is a cytologic technique most often used in the diagnosis of herpesvirus infections [simplex or varicella-zoster. An early vesicle, not a pustule or crusted lesion, is unroofed, and the base of the lesion is scraped gently with a scalpel blade. The material is placed on a glass slide, air-dried, and stained with Giemsa or Wright's stain. Multinucleated epithelial giant cells suggest the presence of herpes, but culture or immunofluorescence testing must be performed to identify the specific virus.

Diascopy

Diascopy is designed to assess whether a skin lesion will blanch with pressure as, for example, in determining whether a red lesion is hemorrhagic or simply blood-filled. For instance, urticaria will blanch with pressure, whereas a purpuric lesion caused by necrotizing vasculitis will not. Diascopy is performed by pressing a microscope slide or magnifying lens against a lesion and noting the amount of blanching that occurs. Granulomas often have an “apple jelly” appearance on diascopy.

Wood's Light

A Wood's lamp generates 360-nm ultraviolet (or “black”) light that can be used to aid the evaluation of certain skin disorders. For example, a Wood's lamp will cause erythrasma (a superficial, intertriginous infection caused by Corynebacterium minutissimum) to show a characteristic coral red color, and wounds colonized by Pseudomonas to appear pale blue. Tinea capitis caused by certain dermatophytes such as Microsporum canis or M. audouini exhibits a yellow fluorescence. Pigmented lesions of the epidermis such as freckles are accentuated, while dermal pigment such as postinflammatory hyperpigmentation fades under a Wood's light. Vitiligo appears totally white under a Wood's lamp, and previously unsuspected areas of involvement often become apparent. A Wood's lamp may also aid in the demonstration of tinea versicolor and in recognition of ash leaf spots in patients with tuberous sclerosis.

Patch Tests

Patch testing is designed to document sensitivity to a specific antigen. In this procedure, a battery of suspected allergens is applied to the patient's back under occlusive dressings and allowed to remain in contact with the skin for 48 h. The dressings are removed, and the area is examined for evidence of delayed hypersensitivity reactions (e.g., erythema, edema, or papulovesicles). This test is best performed by physicians with special expertise in patch testing and is often helpful in the evaluation of patients with chronic dermatitis.