L-31 Approach to Skin Complaints

Clinical Approach to Skin Complaints

• Objectives involve discussing algorithms for clinical presentations of pruritis and rashes.

History

• Inquire about the duration of a skin eruption or lesion.
• Chronic plaque psoriasis can be differentiated from acute contact dermatitis.
• Determine how the rash looked when it first appeared and how it has changed.
• Melanoma can change from symmetrical and flat to asymmetrical and raised.
• Ask where the rash or lesion first appeared and its current location.
• Measles (Roseola) presents as a deep, red, flat rash starting on the face and spreading to the trunk, arms, and legs.
• Fifth Disease (erythema infectiosum) starts on the cheeks, appearing as a bright red, slapped cheek rash that spreads to the trunk, arms, and legs, lasting two to four days.
• Identify associated symptoms like itching, stinging, tenderness, or pain.
• Excruciating pain is associated with Zoster.
• Determine if any family members have similar skin conditions.
• Skin cancer, pemphigus vulgaris, and contact dermatitis may have a genetic component.
• Inquire if the patient has experienced the rash or lesion before, and if so, establish treatment used and its response.
• Rashes often remit and relapse, and skin conditions like psoriasis are known to come and go.
• Ask about the patient's perceived cause of the rash or lesions.
• Inquire about factors that worsen or improve the rash or lesions like antihistamines, cold, or sun exposure.
• Ask about the patient's usual skin care regimen.
• Determine if there are any new or different factors like medications, personal care products, or occupational/recreational exposures, considering the rash's distribution and potential link with detergents on clothes.
• It is critical to ask how the skin problem impacts the patient's life.
• Investigate previous treatments used and the response, noting specific treatments for conditions like seborrheic keratosis or onychomycosis.
• Helpful questions include: acute or chronic illnesses, medications (OTC, herbal supplements), family history of skin conditions/cancer, stress levels, social history (travel, occupation, hobbies), allergies, pets, and STD risk factors.

Physical Exam

• Always visualize the patient's skin in its entirety.
• Look for morphology, distribution, color, consistency, number and arrangement of the lesions.
• Examine nails and hair.
• Mucosal surfaces should be inspected, including mouth, nares, anus and genitals.

Physical Exam of Highly Pigmented Skin

• Erythema is especially difficult to asses in highly pigmented skin
• Erythema appears dark brown/violaceous, instead of pink/purple.
• Conditions like rosacea can be misdiagnosed if erythema and telangiectasias are more difficult to identify.
• Eczema presents as grayish, violaceous, and/or dark brown scaly lesions.
• Urticarial wheals may appear skin-colored or paler due to dermal edema lightening the skin.
• Purpura is difficult to detect as it may be obscured by skin color.
• Dry skin may present a white or ashy color with reduced skin shininess.
• Post-inflammatory hypo or hyperpigmentation.

Palpation of the Skin

• Palpation of the skin is a central diagnostic role
• Intact skin can be palpated without gloves after the hands are washed with gloves worn for non-intact skin, and examinations of the mouth, genitals and perianal area.
• Detects consistency, induration, tenderness, depth and fixation of a lesion
• Exerting pressure on the skin can demonstrate: edema, blanching or dermal defects
• Skin induration caused by morphea or scleroderma dermal fibrosis, may only have detection via palpation with visual inspection confirming hypo/hyperpigmentation.
• Actinic keratoses are more easily "felt" than seen.
• In bullae patients, applying sheer forces may separate the skin, known as Nikolsky sign in pemphigus.
• Stroking or rubbing skin may illicit dermographism .
• Rubbing skin affected by mastocytosis may activate mast cells, causing redness, swelling, & itchiness (Darier's sign in urticaria pigmentosa).

Wood’s Light

• A handheld source of UV light that excludes all visible rays using a Wood's (nickel oxide) filter.
• Aids in visualizing variations in epidermal pigmentation.
• Vitiligo: Displays bright white, sharply demarcated appearance.
• Progressive Macular Hypomelanosis displays hypopigmented lesions with characteristic punctate, orange-red, follicular fluorescence.
• Tinea capitis dermatophytes emit fluorescence.
• Microsporum audouinii and Microsporum canis produce blue-green.
• Trichophyton schoenleinii creates faint, dull blue.
• Erythrasma indicates coral-red fluorescence due to the presence of bacterial coproporphyrin III in intertriginous areas.
• Pityriasis versicolor caused by Malassezia emits a yellow-orange fluorescence.

Biopsy

• Excisional Biopsy removes the entire tumor while incisional biopsy removes a tumor portion.

Shave Biopsy

• Shave biopsy is superficial, and useful for lesions such as warts, paplillomas, skin tags, superficial carcinoma and keratoses
• Shave Biopsies are done parallel to the skin
• A number 15 blade should be used

Punch Biopsy

• Skin punch instrument used extends through to the subcutaneous fat for cylindrical specimen.
• Punch biopsies are either excisional or incisional based on lesion size/tissue type.
• Lesions requiring dermal/subcutaneous tissue such as: inflammatory or bullous lesions, dysplastic nevi, panniculitis, scalp/hair follicle biopsies are done with punch biopsies
• The site should be closed off using sutures
• Avoid removing the punch to avoid ragged wounds

Excisional Biopsy

• Excision entails removing a skin lesion completely, like in skin cancer, along with a margin of surrounding skin (3:1, length:width ratio)
• This improves chances of complete removal.

Rash Presentation History

• 27-year old female with a rash on the chest and back for one week; includes round lesions (no change), itching, with no family history.
• Rash began when she was a kid and went away after using some lotion with no known cause and itching makes it worse.
• Used lotion after showering with sunscreen.
• This new detergent results in these things and it is not too bad and treatment doesn't work

Physical Exam

• Scattered wheals are on the chest, abdomen and back, sparing the neck and forearms, blanching
• There are few excoriations with no underlying erythema or crepitus and non-tender to palpation

Diagnosis and Treatment

• Contact dermatitis secondary to new detergent
• Distribution of rash and 2nd Gen Antihistamine PO QD

Rash Presentation - 65 year-old-male

• 65 with a skin lesion on his head for 3 months that feels like a small skin tag, top of the head, flaking, no pain. In the sun, never used sunscreen, grew up in SFI and was a lifeguard - no tx or response
• Treatment involved: "shave biopsy"

Rash Presenation - 24 year-old-female

• 24 with lesions for 2 days which feels like pimples, it started on the left side which wraps left side
• Pain on palpation, no family history of this, never had it before, no clue for cause and touching it causes pain more
• Moisturing lotion and ibuprofen used with no success

Physical exam - 24 year-old-female

• The rash is tender to palpation, vesicular with erythematous base
• Location has a dermatome of T4-T5

Diagnosis

• Herpes Zoster
• Valacyclovir: 1000 mg three times daily for seven days"

Rash Presentation - 30 year-old-male

• "The woman noticed discoloration on his back" Rash on the back for 2 days, wife called it little spots where he diidn't tan. Complains of Iitching but no family history. Used lotion and used ibuprofen

Physical Exam

• Wood's lamp revealed "Yellow-Green Fluorescence"
• Pityriasis Versicolor due to Malassezia
• Selenium sulfide 2.5% shampoo for ten minutes once a week