Dermatology Module 2: The Skin Exam (UNM PA Program)

Module 2: The Skin Exam Lisa Long, PA-C UNM PA Program  Learning Objectives 1. Describe skin lesions by size, shape, color, and distribution using Dermatology vocabulary. 2. Elicit a focused Dermatological patient history. 3. Describe a focused physical examination of...

Module 2: The Skin Exam Lisa Long, PA-C UNM PA Program  Learning Objectives 1. Describe skin lesions by size, shape, color, and distribution using Dermatology vocabulary. 2. Elicit a focused Dermatological patient history. 3. Describe a focused physical examination of the skin. 4. Describe the use of the following bedside diagnostics: a. Skin scraping and hair shaft: KOH b. Skin scraping: Mineral Oil c. Tzanck smear History  Patient History HPI PMH FH Surgical Hx Social Hx Allergies Medications  Patient History HPI of rash/lesion ○ Onset- When did it start? What were you doing when it started? ○ Location- Where is the area of concern? Is it anywhere else? ○ Progression- Has it come and gone? Spread? Changed in any way? ○ Previous episodes- Is this the first time you’ve had it? ○ What makes it better/worse- What have you tried? Time of day? ○ Quality- Does it itch? Burn? Bleed on it’s own? Hurt? ○ Treatment- What have you tried? Have you been seen by another provider?  Patient History Past Medical History ○ Current illnesses ○ Chronic illnesses ○ History of skin conditions Family History ○ History of eczema, psoriasis? ○ Does anyone else in the household have the same problem? ○ History of skin cancer? Social History ○ Alcohol, drug use, tobacco? ○ Sexual behavior?  Patient History Allergies ○ Atopic triad- asthma, allergic rhinitis, eczema ○ Food? Pets? Seasonal? Medications ○ What are you taking? ○ Have you tried anything to treat the current problem? Is there anything else you can think of? ○ Exposure to anything new? ○ Recent camping or hiking? ○ New products? ○ Recent sun exposure? Physical Exam  Physical Exam Be systematic! Find a routine that works for you, and do it the same way each time. Remember to look EVERYWHERE! ○ Have patient change into a gown for a full body skin exam ○ Behind and in the ears ○ Scalp ○ In the mouth ○ Axilla ○ Bottoms of the feet and between the toes ○ Nails Ask permission before touching and always ask before doing a sensitive exam  Physical Exam Palpate ○ Rough or scaly in a sun exposed area? ○ Flat or raised? ○ Tender or not?  Morphology How to describe cutaneous lesions  Lesion- an anomaly of the skin. The area of interest does not resemble the surrounding skin. Ex: rash, mole, birthmark, skin cancer, benign skin growth, discoloration, scab Primary lesion- arises de novo and can be Morphology something a person is born with or it can be acquired. Ex: macule, papule, patch, plaque, vesicle, bullae Secondary lesion- a change in the primary lesion due to natural progression of the lesion or from trauma to the primary lesion. Ex: ulceration, excoriation, fungation, lichenification Primary Lesions Flat Lesions Macule (1cm) flat, nonpalpable lesions usually demonstrating a change in color Ex: vitiligo, cafe au lait spots, port wine stains Primary Lesions Raised Lesions Papule (1cm) larger lesion that can be palpated Ex: psoriasis, granuloma annulare Primary Lesions Raised Lesions Nodule (>1cm) firm raised lesions, often dome shaped Ex: epidermal inclusion cysts, lipomas Primary Lesions Fluid-filled Lesions Vesicle (1cm) larger, clear fluid filled blisters Ex: bullous pemphigoid, irritant contact dermatitis Purulent Lesions Pustules vesicles that contain pus Ex: folliculitis, paronychia, pimples Wheal Wheal raised, red, pruritic lesions caused by dermal edema Ex: hives (urticaria) Secondary Lesions Result of traumatized primary lesion Excoriation- loss of epidermis and possibly dermis due to scratching Scale- thickening of stratum corneum Fissure- linear cleft in skin, often painful Lichenification- thickening of the skin caused by chronic rubbing or scratching. Seen in atopic dermatitis or lichen simplex chronicus Ulcer- loss of epidermis and at least a portion of the dermis Crust- dry blood, pus, or serum, “scab” Erosion- loss of a portion of the epidermis Secondary Lesions Color and Size Color and Size Keep it simple, describe what you see…  Color Redness Erythema- localized, blanchable, redness caused by increased blood flow Rosacea, surrounds the base of malignancies, rashes, benign lesions  Color Redness Erythroderma- erythema covering at least 80-90% of the body Usually due to inflammation, atopic dermatitis, psoriasis, drug eruption. 30% of the time it’s idiopathic. If sudden onset without hx of inflammatory skin condition, consider systemic disease such as lung cancer, HIV, graft vs host, Sezary Syndrome (CTCL).  Color Redness Telangiectasias- visible, persistent, dilation of superficial blood vessels Color Violaceous Ecchymosis- bruising Non-palpable purpura- actinic purpura Palpable purpura- Henoch Schonlein Distribution  Distribution How are the lesions distributed on the patient’s body? Are they localized? Widespread? Is there one lesion or many lesions? Do you see a pattern or area that is more affected? Distribution Generalized- covers a large body surface area Erythroderma Xerosis  Localized- covers a smaller area Extensor surfaces- elbows, knees Flexural surfaces- antecubital, popliteal fossae Intertriginous- inguinal, axillary, inframammary fold Palms and soles Acrofacial Distribution Distribution Localized Extensor Surfaces Plaque Psoriasis Distribution Localized Flexor surface Atopic dermatitis Distribution Localized Intertriginous- affecting one or more of the major body folds Inguinal, axillary, inframammary fold Distribution Localized Palms and soles Palmoplantar psoriasis, syphilis Distribution Localized Acrofacial Vitiligo  Linear lichen striatus Distribution Dermatomal herpes zoster Distribution Photodistribution Dermatitis in areas often exposed to UV rays PMLE, drugs, lupus  Now put it all together and describe what you see…. A 33 yo male presents with several pruritic lesions on his lower back and buttock area. He says they have come and gone for several years, but he hasn’t been able to see a doctor due to lack of insurance, so he has never tried any treatment other than lotion. A 66 yo old female presents with a “bump” on her right temporal region that bleeds spontaneously and has been there for about 2 months. She states that it must be a pimple that won’t heal. A 40 yo female presents with a mole on her right posterior upper back. She thinks it has been there for as long as she can remember, but her husband thinks it has changed. A 69 yo male presents with concerns about brown warts that have taken over his entire back. He says he‘s worried that he has leprosy. A 21 yo female presents with a red rash and small pimples around her mouth. She says it has been there for several months and she’s tried every over the counter acne product she can think of, but it’s only gotten worse. A 68 yo female presents with strange purple spots on her arms that she first noticed several months ago. She says they develop out of nowhere, last for a couple of weeks, and are not tender. She thinks they may have started around the time she was put on apixaban (Eliquis) Bedside Diagnostics  Bedside Diagnostics Potassium Hydroxide (KOH) Mineral Oil Tzanck Smear  Used to confirm superficial fungal infections of skin, hair, or nails Tinea versicolor Potassium Tinea corporis, cruris, pedis Hydroxide (KOH) Candidiasis Required equipment Microscope Glass slide with cover 20% Potassium Hydroxide (KOH) Scalpel blade Potassium Hydroxide (KOH) Procedure Use scalpel to gentle scrap skin cells for area of concern Place the sample on a clean glass slide Add 1 drop 20% KOH and place glass cover on top of sample Allow specimen to sit 5-10 minutes, or heat for a few seconds View under microscope, looking for hyphae Mineral Oil Scraping Used to diagnose suspected scabies Required equipment Scalpel blade Glass slide and cover Mineral Oil Microscope Procedure Place 2-3 drops of mineral oil on glass slide Scrape area of concern (burrows, inflammatory papules) Place sample on slide and cover Examine under the microscope Tzanck Smear Used to diagnose suspected herpes simplex and zoster infections Most sensitive if sample is taken when intact bullae are present Required equipment Scalpel blade Glass slide Giemsa stain Microscope Procedure Gently retract roof of blister then scrape the base of the vesicle Place sample on slide and allow to dry Stain with Giemsa stain Examine under microscope looking for multinucleated giant cells Thank you!