Approach To Derm Patient PDF

Approach to the Derm Patient: The Skin, Hair and Nails History and Physical Lee Scott, MD 1 End of Semester! Thanks for a great year!!! 2 Objectives Obtain an appropriate history for a patient...

Approach to the Derm Patient: The Skin, Hair and Nails History and Physical Lee Scott, MD 1 End of Semester! Thanks for a great year!!! 2 Objectives Obtain an appropriate history for a patient with a skin, hair, or nail concern. Describe the examination of the hair including the hair pull test and the tug test. Distinguish benign findings from malignant findings of the skin and nails. State the USPSTF recommendations for skin cancer screening exams. Recognize the risk factors for skin cancer, particularly melanoma. Describe the examination of the skin. Describe and document skin lesions using terminology taught in this lecture. Recognize how conditions vary in presentation on various skin colors. Recognize skin findings indicative of sun damage Identify patients at risk for pressure ulcers. Skin, Hair, and Nails Patients may come in with a skin, hair, or nail problem as their chief concern. OR You may uncover a skin, hair or nail problem as part of your review of systems or physical exam. Common presenting symptoms include: A rash A lump or lesion Pruritus (itch) Hair loss or excess hair (hirsutism, hypertrichosis) Nail changes History Taking Ask if the patient is concerned about any new growths or rashes: “Have you noticed any changes in your skin? …your hair? …your nails?” “Have you had any rashes? …sores? …lumps? …itching?” History Taking If the patient has a skin/hair/nail symptom - Ask: When did the lesion appear or the rash begin? Where is the rash/lesion? Has the rash spread, or the lesion changed, since its onset? Is the lesion tender or painful? Is the rash itchy? Is the itch intense enough to cause bleeding by scratching or to disturb sleep, as in atopic eczema and lichen simplex? Are there blisters? Does itching precede the rash or follow the rash? Is there itching with NO rash? Patients may have generalized itching, without apparent rash: Dry skin Drug reactions Pregnancy Polycythemia vera Uremia Thyroid disease Jaundice Lymphomas and leukemia History Taking Ask: Do the symptoms vary with time? For example, the pruritus of scabies is usually worse at night, and acne and atopic eczema may show a premenstrual exacerbation. Were there any preceding symptoms, such as a sore throat in psoriasis, a severe illness in telogen effluvium, or a new oral medication in drug eruptions? Are there any aggravating or relieving factors? For example, exercise or exposure to heat may precipitate cholinergic urticaria. What, if any, has been the effect of topical or oral medications? Self-medication with oral antihistamines may ameliorate urticaria, and topical glucocorticoids may help inflammatory reactions. Are there any associated constitutional symptoms, such as joint pain (psoriasis), muscle pain and weakness (dermatomyositis), fever, fatigue or weight loss? Very importantly, what is the impact of the rash on the individual's quality of life?  History Taking Specifically for hair loss: Ask if there is hair thinning or hair shedding and, if so, where. What is the pattern? The most common causes of diffuse hair thinning are male and female pattern baldness. If shedding, does the hair come out at the roots or break along the hair shafts? Hair shedding at the roots is common in telogen affluvium and alopecia areata. Ask about hair care practices like frequency of shampooing and use of dyes, chemical relaxers, or heating appliances. Hair breaks along the shaft suggest damage from hair care or tinea capitis. As mentioned before, ask about preceding severe illness or recent pregnancy. Acuity of onset? alopecia areata Past medical and medication history Ask about general health and previous medical or skin conditions. A history of asthma, hay fever or childhood eczema suggests atopy. Celiac disease is associated with dermatitis herpetiformis. Take a full medication history, including any recent oral or topical prescribed or over-the-counter medication. Inquire about allergies not just to medicines but also to food or environmental allergies. Family and social history Inquire about occupation and hobbies, as exposure to chemicals may cause contact dermatitis. If a rash consistently improves when a patient is away from work, the possibility of industrial dermatitis should be considered. Document foreign travel if tropical infections are being considered. Ask about sun exposure if actinic damage or photosensitive eruptions are being considered. The risk of squamous cell and basal cell cancers increases with total lifetime sun exposure, and intense sun exposures leading to blistering burns are a risk factor for melanoma. Ask about tanning bed use. Use of indoor tanning beds, especially before age 35 years, increases risk of melanoma by as much as 75%. Ask about a family history of atopy and skin conditions. History Taking If the patient reports a new growth, it is important to pursue the patient's personal and family history of skin cancer. Note the type, location, and date of any past skin cancer and ask about regular self-skin examination and use of sunscreen. Also ask “Has anyone in your family had a skin cancer removed?” If so, who? Do you know what type of skin cancer—basal cell carcinoma, squamous cell carcinoma, or melanoma?” Document the response even if the patient does not know which type. History Taking If the patient reports a new growth or concerning lesion, assess for melanoma risk factors. Personal or family history of previous melanoma ≥50 common moles Atypical or large moles, especially if dysplastic Note: Some of these are Red or light hair physical exam findings. Solar lentigines (acquired brown macules on sun-exposed areas) Freckles (inherited brown macules) Ultraviolet radiation from heavy sun exposure, sunlamps, or tanning booths Light eye or skin color, especially skin that freckles or burns easily Severe blistering sunburns in childhood Immunosuppression from human immunodeficiency virus (HIV) or from chemotherapy Personal history of nonmelanoma skin cancer Examining the Hair and Scalp With the patient seated on the examining table, stand in front of the patient and adjust the table to a comfortable height. Separate the hair to examine the scalp from one side to the other. You may need to use your fingers or a cotton-tipped applicator (“Q-tip”) to separate the hair to see the scalp. Note the distribution, texture, and quantity of hair. Remember to inspect the ears! Examining the Patient with Hair Loss Based on the patient's history, start by examining the hair to determine the overall pattern of hair loss or hair thinning. Inspect the scalp for erythema, scaling, pustules, tenderness, bogginess, and scarring. Look at the width of the hair part in various sections of the scalp. To examine the hair for shedding from the roots, perform a hair pull test by gently grasping 50 to 60 hairs with your thumb and index and middle fingers, pulling firmly away from the scalp. If all the hairs have telogen bulbs, the most likely diagnosis is telogen effluvium. To examine the hair for fragility, perform the tug test by holding a group of hairs in one hand, pulling along the hair shafts with the other; if any hairs break, it is abnormal. Most (97%) hair loss is nonscarring, but any scarring, namely shiny spots without any hair follicles on close examination with a magnifying glass, should prompt referral to dermatology for scalp biopsy. Generalized or Diffuse Hair Loss Male and female pattern hair loss affects over half of men by their 50 years of age, and over half of women by their 80 years of age. In men, look for frontal hairline regression and thinning on the posterior vertex; in women, look for thinning that spreads from the crown down without hairline regression. The hair pull test is normal or only pulls a few hairs. Focal Hair Loss Alopecia Areata There is sudden onset of clearly demarcated, usually localized, round or oval patches of hair loss leaving smooth skin without hairs, in children and young adults. There is no visible scaling or erythema. Tinea Capitis (“Ringworm”) There are round scaling patches of alopecia, mostly seen in children. There may be “black dots” of broken hairs and comma or corkscrew hairs on dermoscopy. Usually caused by Trichophyton tonsurans from humans, and less commonly, Microsporum canis from dogs or cats. Boggy plaques are called kerions. Focal Hair Loss Scarring Alopecia Scarring on the scalp is characterized by shiny skin, complete loss of hair follicles, and often, discoloration. Presence of any scarring should prompt referral to a dermatologist for possible scalp biopsy if the patient desires treatment. Examples of scarring alopecia include central centrifugal scarring alopecia and discoid lupus erythematosus, among others. Nails Nails Paronychia- A superficial infection of the proximal and lateral nail folds adjacent to the nail plate. The nail folds are often red, swollen, and tender Clubbing- Clinically, a bulbous swelling of the soft tissue at the nail base, with loss of the normal angle between the nail and the proximal nail fold. Nails Onychomycosis- The most common cause of nail thickening and subungual debris is onychomycosis, most often from the dermatophyte Trichophyton rubrum, but also from other dermatophytes and some molds such as Alternaria and Fusarium species. Pitting- Punctate depressions of the nail plate caused by defective layering of the superficial nail plate by the proximal nail matrix. Usually associated with psoriasis but also seen in Reiter syndrome, sarcoidosis, alopecia areata, and localized atopic or chemical dermatitis.  Nails Melanonychia- Melanonychia is caused by increased pigmentation in the nail matrix, leading to a streak as the nail grows out. This may be a normal ethnic variation if found in multiple nails. A thin uniform streak may be caused by a nevus, but a wide streak, especially if growing or irregular, could represent a subungual melanoma. Subungal melanomas longitudial melanonychia Imatinib-induced transverse melanonychia Examination of the Skin Incorporate this into your overall physical examination. Although the USPSTF found insufficient evidence (Grade I) to recommend routine skin cancer screening by primary care physicians, it does advise clinicians to “remain alert for skin lesions with malignant features” during routine physical examinations and reference the ABCDE criteria. (2016) Since the USPSTF review, an important German study of over 350,000 patients reported that full-body primary care screening with dermatology referrals for concerning lesions reduced melanoma mortality by more than 47%. Survival from melanoma strongly correlates with tumor thickness. Two further studies demonstrate that patients receiving skin examinations are more likely to have thinner melanomas. Examination of the Skin Inspect and palpate all skin lesions, focusing on key features that help distinguish if lesions are benign or suspicious for malignancy. Are they raised, flat, or fluid-filled? Are they rough or smooth? What about color? Is the lesion pink or brown or black? Measure the size. Is the size changing? Changing moles, History of skin cancer Other risk factors All warrant a full-body skin examination. Examination of the Skin Instead of focusing on what is not present on the skin, it may help to focus on what is present. Have a tape measure and a light Don’t miss spots! Tops of ears Bottoms of feet Between toes Learn to distinguish normal skin lesions from abnormal lesions and potential skin cancers. Identify skin findings associated with systemic illnesses. Describing Skin Findings Primary lesion: Primary lesions are flat or raised. Flat: You cannot palpate the lesion with your eyes closed. Macule: Lesion is flat and ≤1 cm. Patch: Lesion is flat and >1 cm. Raised: You can palpate the lesion with eyes closed. Papule: Lesion is raised, ≤1 cm, and not fluid filled. Plaque: Lesion is raised with flat-top, >1 cm, and not fluid filled. Nodule: Lesion is raised with spherical contour, >1 cm, and not fluid filled. Vesicle: Lesion is raised, ≤1 cm, and filled with fluid. Bulla: Lesion is raised, >1 cm, and fluid filled. Other primary lesions include erosions, ulcers, ecchymoses, petechiae, and purpura. Describing Skin Findings Number: Lesions can be solitary or multiple. If multiple, record how many. Consider estimating the total number of the type of lesion you are describing if they are numerous. Size: Measure with a ruler in millimeters or centimeters. For oval lesions, measure in the long axis, then perpendicular to the axis. Shape: Some good words to learn are: “circular” “oval” “annular” (ring-like, with central clearing) “nummular” (coin-like, no central clearing) “polygonal” (varied non-geometric shape) Polygonal Lesions Describing Skin Findings Color There are many shades of tan and brown Start with tan, light brown, and dark brown if you are having trouble. Use “skin-colored” to describe a lesion that is the same shade as the patient's skin. Some lesions may need to be described with other “colorful” names such as bright red, purple, or violaceous. Describing Skin Findings Blanching vs. Nonblanching: For red lesions or rashes, blanch the lesion by pressing it firmly with your finger or a glass slide to see if the redness temporarily lightens then refills. Blanching lesions are erythematous and suggest inflammation. Nonblanching lesions such as petechiae, purpura, and vascular structures are not erythematous, but rather bright red, purple, or violaceous. Describing Skin Findings Texture Palpate the lesion to see if it is: Smooth Fleshy Scaling can be: Verrucous or warty Greasy seborrheic dermatitis Scaly (fine, keratotic, or greasy scale). Dry and fine tinea pedis Hard and keratotic actinic keratoses or SCC Location: Be as specific as possible. For single lesions, measure their distance from other landmarks (e.g., 1 cm lateral to left oral commissure). Describing Skin Findings Configuration: Although not always necessary, describing patterns is often very helpful. A Examples: A. poison ivy allergic contact dermatitis with linear lesions. B. herpes zoster with unilateral and B dermatomal vesicles C. herpes simplex, with grouped vesicles or pustules on an erythematous base C If a rash or discoloration is everywhere, call it “generalized.” Describing Skin Findings Flat Spots If you run your finger over the lesion but do not feel the lesion, the lesion is flat. If a flat spot is small (≤1 cm), it is a macule. If a flat spot is larger (>1 cm), it is a patch. Macules – flat and small (< 1 cm ) 35 Macules – flat and small ( < 1 cm) Patches – flat and large (> 1 cm) Seborrheic dermatitis Vitiligo Patches – flat and large ( > 1 cm) Describing Skin Findings – Raised Spots If you run your finger over the lesion and it is palpable above the skin, it is raised. If a raised spot is small (≤ 1 cm), it is a papule. If a raised spot is larger (>1 cm), it is a nodule or plaque. Papules – raised and small Plaques – raised and large: Scattered erythematous Single, oval, flat-topped Multiple round to oval to bright pink well- superficial scaling violaceous circumscribed flat- erythematous to skin- plaques on abdomen topped plaques on colored plaque on right and back: extensor knees and abdomen: Pityriasis rosea elbows, with overlying Herald patch of silvery scale: pityriasis rosea plaque psoriasis Plaques – raised and large Bilateral erythematous, lichenified (thickened from rubbing) poorly circumscribed plaques on flexor wrists, antecubital fossae, and popliteal fossae; atopic dermatitis Multiple round coin-like eczematous plaques on arms, legs, and abdomen, with overlying dried transudate crust; nummular dermatitis (aka nummular eczema) Fluid filled If the lesion is raised, filled with fluid, and small (≤1 cm), it is a vesicle. If a fluid-filled spot is larger (>1 cm), it is a bulla. Vesicles: fluid-filled and small Multiple 2 – 4 mm Grouped 2 – 5 mm vesicles Scattered 2 – 5 mm vesicles and on erythematous base in a erythematous papules pustules on dermatomal distribution and vesicles with erythematous base, that does not cross the transudate crust some grouped together: midline: with linear arrays, on herpes simplex virus herpes zoster or “shingles” forearms, neck, and abdomen: rhus dermatitis or allergic contact dermatitis from poison ivy Bullae – fluid-filled and large Solitary 8 cm dusky Several tense bullae: Many vesicles and tense oval patch with Insect bites bullae up to 4 cm, some smaller inner having unroofed and left violaceous patch large 4 cm erosions, on and central 3.5 cm lower legs bilaterally up to tense bulla, on right the line of the top of posterior lower combat boots: an back: bullous fixed inherited skin fragility drug eruption disorder Additional Primary Lesions Pustule: A vesicle containing inflammatory cells. Appears white Additional Primary Lesions Furuncle: Inflamed hair follicle A “boil” Carbuncle: Multiple furuncles together “Fluctuant”-can be compressed. Abscesses are fluctuant. Additional Primary Lesions Nodule: Larger and deeper than a papule From Dr. Lyons’ slide: Elevated lesion with spherical contour >1cm in diameter Additional Primary Lesions Subcutaneous mass/cyst: Whether mobile or fixed, cysts are encapsulated collections of fluid or semisolid. Additional Primary Lesions Erosion: focal loss of epidermis Ulcer: focal loss of Burrow: Small linear or epidermis along with serpiginous pathways in some dermis the epidermis created by the scabies mite Wounds Abrasion: wound caused by superficial damage to the skin, no deeper than the epidermis. Laceration: a cut of the skin (incision if therapeutically made) Vascular and Purpuric Lesions Spider Angioma: common on the face and chest. May appear in pregnancy or liver disease. Spider veins: most often on the legs. Often accompanies increased pressure in the superficial veins. Cherry angioma: trunk and extremities. Increase in size and number with age. Vascular and Purpuric Lesions Petechiae Ecchymosis Benign Lesions Practice makes perfect… Look for these common lesions during your clinical rotations. Perform a skin examination on as many patients as you can. If you are unsure about identifying the lesion, ask your instructors or attending physicians for help. Seborrheic keratosis Solar lentigines Benign Lesions Epidermal inclusion cyst Pilar cyst Lipoma Benign Lesions keloid dermatofibroma Benign melanocytic nevi Benign Lesions – darker skin Dermatosis papulosa nigra is a condition of hyperpigmented, hyperkeratotic plaques similar to seborrheic keratoses and acrochordons (skin tags), both clinically and histologically. Dermatosis papulosa nigra growths are common and usually are found on the face and neck, with a particular predilection for periorbital skin of darkly pigmented persons. Approximately 50% of the black population has these benign growths, and women are more affected than men by a ratio of 2:1. Benign Lesions – darker skin Keloids Benign Lesions – darker skin Dermal Melanocytosis. (Mongolian Spots) Darker Skin – recognizing conditions Atopic Dermatitis (eczema) Darker skin – recognizing conditions Psoriasis Finding Skin Cancers Is the patient at risk?? History (previous slides) Sun Damage on exam Finding the Ugly Duckling: As you evaluate changing brown lesions in the context of the patient's other nevi and lentigines, the “ugly duckling” is the nevus that looks different from the patient's other nevi. A patient may make many atypical nevi with surrounding macular components and central papular components, but they all look the same. Find the patient's signature nevus, then search for the ugly duckling that looks different from the patient's typical “signature” nevi. The ABCDE Rule If two or more of these are present, risk of melanoma increases and biopsy should be considered. Some have suggested adding EFG to help detect aggressive nodular melanomas. Asymmetry Border Irregularity Color variations Diameter>6mm Evolving Elevated Firm to palpation Growing progressively over several weeks The ABCDE Rule Melanoma Mimics Pressure Ulcers Pressure (decubitus) ulcers usually develop over bony prominences subject to unrelieved pressure, resulting in ischemic damage to underlying tissue. Pressure ulcers form most commonly over the: sacrum ischial tuberosities greater trochanters heels Prevention is important: inspect the skin thoroughly for early warning signs of erythema that still blanches with pressure, especially in patients with risk factors. Risk Factors: Decreased mobility Decreased sensation Decreased blood flow from hypotension or microvascular disease such as diabetes or atherosclerosis Fecal or urinary incontinence Presence of fracture Poor nutritional status or low albumin Inspect ulcers for signs of infection (drainage, odor, cellulitis, or necrosis). Pressure Ulcers Staging Recording Your Findings Use specific terms to describe skin lesions and rashes, including: Number—solitary or multiple; estimate of total number Size—measured in millimeters or centimeters Color—including erythematous if blanching; if nonblanching, vascular- like cherry angiomas and vascular malformations, petechiae, or purpura Shape—circular, oval, annular, nummular, or polygonal Texture—smooth, fleshy, verrucous or warty, keratotic; greasy if scaling Primary lesion—flat, a macule or patch; raised, a papule or plaque; or fluid filled, a vesicle or bulla (may also be erosions, ulcers, nodules, ecchymoses, petechiae, and palpable purpura) Location—including measured distance from other landmarks Configuration—grouped, annular, linear Recording the Skin, Hair, and Nails Physical Examination “Skin warm and dry. Nails without clubbing or cyanosis. Approximately 20 brown, round macules on upper back, chest, and arms, are all symmetric in pigmentation, none suspicious. No rash, petechiae, or ecchymoses.” “Marked facial pallor, and circumoral cyanosis. Palms cold and moist. Cyanosis in nail beds of fingers and toes. Numerous palpable purpura on lower legs bilaterally.” “Scattered stuck-on verrucous plaques on back and abdomen. Over 30 small round brown macules with symmetric pigmentation on back, chest, and arms. Single 1.2 × 1.6 cm asymmetric dark brown and black plaque with erythematous, uneven border, on left upper arm.” Questions? Lee Scott, M.D. [email protected] Rm. 215 (Dr. Pimple Popper)