1. Dermatological History and Examination
age, sex
Chief complaint : + duration
itching
burning
pain
History of present illness
When and how started?
Mild, moderate or severe?
Aggravating or reliving factors?
Any other symptoms
Review of systems
Past medical history
Drug history

2. Occupation Hobbies Travel Family history

3. Examination: 3 corners to make useful skin exam
Morphology (shape of the lesion)
Configuration (arrangement of lesions)
Distribution (Which body site)
Morphology:
1º skin lesions : unmodified lesions
2º skin lesion: modified by scratching or infection

4. Primary Lesions Secondary lesions
Macule Crust
Papule Erosion
Plaque Scale
Nodule Ulceration
Cyst Excoriation
Wheal Scar
Vesicle Atrophy
Bulla Fissure
Purpura Necrosis
Burrow Lichenification
Telangectasia

5. Primary skin lesions

6. Macule & patch
A macule is a circumscribed flat alteration in the colour of the skin which is less than 1 cm in diameter.
Various colors depending on the cause
A patch is a flat lesion greater than 1 cm in diameter (i.e. a large macule).

7. Papule
A papule is a circumscribed palpable elevation of the skin less than 1 cm in diameter
Dermal(drug eruption, lipid deposits), epidermal (warts, molluscum), or both (lichen planus)

8. Nodule Palpable solid deep lesion (depth> diameter) - Epidermal

9. Plaque A slightly raised lesion greater than 1 cm in diameter
Papules confluence (psoriasis)
Patch thickening (mycosis fungoides)

10. Vesicle
A raised lesion less than 0.5 cm in diameter containing clear fluid

11. Bulla
A vesicle that is greater than 0.5 cm in diameter is known as a bulla.

12. Pustule
A pustule is a raised lesion less than 0.5 cm in diameter containing yellow fluid, which may be sterile as in acne or pustular psoriasis, or infected.

13. Wheal
A wheal is a transient, itchy, pink or red swelling of the skin, often with central pallor.

14. Cyst:
palpable soft sac containing fluid.
- Epidermal
- Dermal

15. Telangiectasia
Dilatation of capillaries gives rise to this skin condition.

16. Secondary skin lesions

17. Crust
A crust is a dried exudate, which may have been serous, purulent or haemorrhagic.

18. Excoriation
A haemorrhagic excavation of the skin resulting from scratching.

19. Lichenification
Thickening of the skin with exaggeration of the skin creases.

20. Scar
The final stage of healing of a destructive process (disease or injury) that has involved the deeper dermis results in a white, smooth, firm, shiny lesion.
Atrophic, or hypertrophic

21. Scale A scale is a flat plate (lamella) or flake of stratum corneum.
The epidermis is replaced in cycles
Fine (eczema) / thick (psoriasis)
No scaling in dermal pathologies

22. Poikiloderma
This refers to an appearance of pigmentation, atrophy and telangiectasia

23. Necrosis
Death, or necrosis, of skin tissue is usually black in colour.

24. Erosion A partial break in the epidermis is known as an erosion
It heals without scarring unless secondary infection occurs.
Commonly following a blister

25. Ulcer An ulcer is a full-thickness loss of the epidermis
Heals with scarring

26. FISSURE
a linear cleavages or cracks in the skin.

27. Atrophy Thinning and transparency of the skin
Caused by diminution of the epidermis, the dermis, or both
Wrinkling and translucency

28. Primary Lesions
Macule: Flat circumscribed area of change in skin color
Papule: small circumscribed elevation of the skin
Nodule:Solid, circumscribed elevation of the skin whose greater part is beneath skin surface (felt more than seen)
Plaque: flat topped palpable lesion (gathering of papules)
Vesicle: collection of clear fluid (<5mm in diameter)
Bulla: like vesicle, but > 5 mm
Pustule: Collection of Pus

29. Primary Lesions
* Wheal: Transient, slightly raised lesion with pale center and pink margin.Seen in urticaria.
* Purpura:Visible collection of blood under the skin e.g. Vasculitis
* Telangectasia: Dilated capillaries visible on skin surface
* Burrow: Tunnel in the skin (e.g. Scabies)

30. Secondary lesions Crust: Dried serum (or exudate)
Scale:Thickened, loose, readily detached fragment of
cornified layer
Excoration: Shallow linear abrasion caused by
scratching.
Erosion:Loss of epidermis (heals without scarring)
Ulcer: loss of epidermis and dermis (heals with
scarring)
Fissure : linear crack in the skin
Scar: Permanent lesion due to abnormal formation of
connective tissue following injury.

31. Secondary lesions
Atrophy: A-Superficial: thining of skin with visible blood vessels
B-Deep : depression of skin surface
Lichenification: thickened skin with
accentuated skin markings
Sclerosis: induration of skin

39. Distribution Predilection for specific body sites
*Psoriasis: Extensors(elbows and knees)
Scalp
*Acne:Face
Upper chest, Upper back
*Photosensitive eruption: Mainly face, forearms & V-Chest (with sparing of photoprotected areas e.g. upper eyelids, retro-auricular an sub- mental)

41. Colour in Dermatology Red:Vascular lesions e.g. port wine stain
also, inflammatory disorders like psoriasis
Blue: Blue nevus
Mongolian spot
Yellow: Xanthoma
White: Vitiligo
Black: Melanocytic nevus & melanoma
Purple or (Violaceous) : Lichen planus

44. Some important signs in Dermatology
*Auspitz sign: When you remove a scale from psoriasis lesion  tiny bleeding points (due to suprapapillary thinning).
Nikolsky sign: When you rub normal skin beside blister  induction of new blister .Seen in pemphigus vulgaris and toxic epidermal necrolysis(TEN).

45. Nikolsky sign

46. Dermatographism: When you stroke the normal skin  edema and erythema (you can write on skin!) .Seen in physical urticaria
Kobener Phenomenon: Induction of new skin lesions on previously normal appearing skin by truma e.g. in psoriasis, wart, lichen planus
Button-hole sign: In neurofirbroma, if you try to push it  it goes inside the skin

47. Kobener Phenomenon

48. Dermatographism

49. Additional skin examination:
~Wood’s Lamp: Produces long wave ultraviolet light(UVA). e.g.
Vitiligo  milky white
Tinea Versicolor  golden
Tinea Capitis (caused by microsporum)  yellow green
Erytherasma  coral red
~Diascopy:you press with a glass slide .
If there is red lesion and the redness dose not go away by this pressure  this means extravasated blood i.e.purpura
~Dermatoscopy: Helpful to differentiate benign from malignant pigmented lesions.

51. Diascopy

52. Investigations: *KOH and fungal culture
Scrap skin scales  put over glass slide
Add KOH 10% -- warm gently
See under microscope
You may see hyphae and/ or spores
*Gram stain and bacterial culture

53. Investigations:
Tzank smear: Scrap base of vesicle smear it on microscopic slide  add fixative  add Giemsa stain.
Examine under microscope for
1.Detached epidermal cells (acantholytic cells) in pemphigus vulgaris
2.Multinucleated giant cells in herpes simplex, zoster or varicella
Viral culture

54. important in immunobullous disorder 1. Direct : use pt’s skin
Skin biopsy : Under local anasthesia, different types: Punch
Shave
Excisional
Incisional
Immunofloursence :
important in immunobullous disorder
1. Direct : use pt’s skin
2. Indirect: use pt’s Serum

59. Thank you