dermatological history and examination

Dermatological History and Examination

Natapol Pumipuntu,DVM

• Contents• โรคผิ�วหนังในัสุ นัข• ข�นัตอนัการตรวจว�นั�จฉัย - History taking - Physical Examination - Differential Diagnosis - Diagnosis Test & Clinical pathology - Tentative Diagnosis & Definitive Diagnosis• การรกษาเบื้��องต�นั

• จ�าแนักตามสุาเหต ของโรคได้�ด้งนั!�

• Parasitic diseases• Bacterial skin diseases• Viral, Protozoal and Rickettsial skin

disease• Fungal skin diseases• Hypersensitivities• Autoimmune dermatoses

• จ�าแนักตามสุาเหต ของโรคได้�ด้งนั!�(ต"อ)

• Endocrine dermatoses• Nutritional dermatoses• Neoplastic dermatoses• Psychogenic dermatoses• Congenital and hereditary dermatoses• Miscellaneous dermatoses

• Parasitic diseases

• Demodex canis• Sarcoptes scabiei• Otodectes cynotis• Cheyletiella spp.• Tick• Flea• Fly

Demodex canis

Sarcoptic mange

Otodectes cynotis

• Bacterial skin diseases

• Staphylococcus intermedius (coagulase-positive & Gram-positive coccus)

• Bacterial skin diseases (cont)

• Surface infections - pyotraumatimatic dermatitis

(Hotspot) - fold pyoderma

• Bacterial skin diseases (cont)

• Superficial infections - impetigo - Superficial folliculitis

• Bacterial skin diseases (cont)• Deep infections - Deep folliculitis - Deep pyoderma - cellulitis - mycobacterial infections

• Viral, protozoal and Ricketsettsial skin diseases

• Viral : canine distemper virus canine viral papillomatosis etc.• Protozoal : canine leishmaniasis etc.• Bacteria : Ehrlichia canis etc.

• Fungal skin diseases

• Fungi - Microsporum canis - Microsporum gypseam - Trichophyton mentagrophytes• Yeast - Malassezia patchydermatis

• Hypersensitivites

• Allergic contact dermatitis• Inhalant allergy• Adverse reaction to food• Drug eruption

etc.

• Autoimmune dermatoses

• Lupus erythematosus• Pemphigus foliaceus• Pemphigoid syndrome• Alopecia areata• Discoid lupus erythematosus• Pemphigus vulgaris

• Endocrine dermatoses

• Hypothyroidisim• Hyperadrenocorticism• Gonadal hormones• Growth hormone etc.

• Nutritional dermatoses

• Protein/calorie deficiency• Essential fatty acid deficiency• Vitamin A deficiency• Vitamin E deficiency• Zinc deficiency

• Neoplastic dermatoses

• Tumors of epithelial origin : Papilloma, Basal cell tumor, Sebaceous gland tumor, Squamous cell carcinoma etc.

• Neoplastic dermatoses (cont)

• Tumors of mesenchymal origin : Fibroma, Fibrosarcoma, Lipoma, Liposacoma, Mast cell tumor etc.

• Neoplastic dermatoses (cont)

• Tumors of lymphohistiocytic origin : Histiocytosis, cutaneous lymphoma, Transmissible venereal tumor etc.

• Psychogenic dermatoses

• Lick dermatitis

• Miscellaneous dermatoses

• Congenital dermatoses• Hereditary dermatoses• Keratinization disorder• Metabolic dermatitis

ขั้��นตอนการวิ�น�จฉั�ยโรคผิ�วิหน�งHISTORY

Physical Examination

Differential Diagnosis

Diagnosis Test & Clinical Pathology

Tentative Diagnosis or Difinitive Diagnosis

Treatment

• การซั�กประวิ�ต� (History Taking)

• การซักประวต�ข�อม&ลพื้��นัฐานั• ข�อม&ลของเจ�าของสุตว* เช่"นั ช่�,อ ที่!,อย&" เบื้อร*โที่ร• ข�อม&ลประจ�าตวสุตว* เช่"นั ช่�,อ พื้นัธุ์ * อาย ประวต�

วคซั!นั ประวต�ที่�าหมนั ฯลฯ

• ซักประวต�ที่ ,วไป เช่"นั อาหาร สุภาพื้แวด้ล�อม ที่!,นัอนั จ�านัวนัสุตว*ที่!,เล!�ยงรวมกนั ฯลฯ

CHIEF COMPLAINT

ซั�กประวิ�ต�เน�นระบบผิ�วิหน�ง

• การซักประวต�เนั�นัระบื้บื้ผิ�วหนัง• วนัที่!,/อาย ที่!,พื้บื้ป1ญหาของผิ�วหนังคร�งแรก• ลกษณะของการเก�ด้เป4นัแบื้บื้ที่นัที่!ที่นัใด้หร�อค"อยเป4นัค"อยไป

• …พื้บื้ในัช่"วงฤด้&ใด้ฤด้&หนั6,งหร�อไม" ฤด้&อะไร• ความผิ�ด้ปกต�ของผิ�วหนังเก�ด้ข6�นัคร�งแรกที่!,ต�าแหนั"งใด้• ลกษณะของความผิ�ด้ปกต�ที่!,พื้บื้ม!ลกษณะเป4นัอย"างไร• สุตว*คนัหร�อไม" คนัอย"างไรตลอด้เวลา/เป4นัคร�งคราว/เฉัพื้าะกลางค�นั

• ต�ด้ต"อไปยงสุตว*ตวอ�,นั/ช่นั�ด้อ�,นัหร�อไม"• สุตว*ตวอ�,นัหร�อคนัเล!�ยงม!ป1ญหาของผิ�วหนังหร�อไม"• … …เคยใช่�ยารกษามาก"อนัหร�อไม" ยาอะไร .ตอบื้สุนัองต"อการรกษาหร�อไม"

• การซักประวต�เนั�นัระบื้บื้ผิ�วหนัง

• เจ�าของค�ด้ว"านั"าจะเก�ด้จากสุาเหต ใด้• อะไร/สุ�,งใด้ที่!,ที่�าให�อาการของป1ญหาผิ�วหนังร นัแรงมากข6�นั

• …เคยพื้บื้เห7บื้หมด้บื้นัตวสุ นัขหร�อไม" ว�ธุ์!ก�าจด้/ป8องกนั

• … การอาบื้นั��า ความถี่!, แช่มพื้&ที่!,ใช่� ลกษณะ ของการอาบื้นั��า ฯลฯ

• History

• Breed• Age• Sex• Environment• Diet• Health status• History of disease• Response to previous treatments

• การตรวจร"างกาย(Physical Examination)

• Physical Examination

• ต�าแหนั"งของว�การ

• Physical Examination

• ร&ปแบื้บื้การกระจายของว�การ - Bilaterally symmetric lesion - Asymmetric lesion

• Physical Examination

• ร&ปลกษณะของว�การ - Single - Linear - Annular

ANNULAR LESION

ARCIFORM LESION

LINEAR LESION

• Physical Examination

• ลกษณะของว�การ - Primary Lesions - Secondary Lesions

• <<Primary Lesions>>• Macules & Patches - Discoloration of the skin - macules less than 1 cm in diameter - patches larger than 1 cm in diameter

***The change is colour may result from pigment loss or excess, erythema or haemorrhage.

• Papules & Plaques

• A circumscribed, solid elevation of the skin

• Papules less than 1 cm in diameter (often pink and red)

• Plaques larger than 1 cm in diameter

• Pustules

• Circumscribed elevations of the superficial layers of the epidemis

• Bacterial infection• The infiltrate will contain

neutrophils, bacteria, debris and perhaps a few free keratinocytes

PUSTULE

**The most important cause is Staphylococcus intermedius

• Wheals• More or less well-defined

elevations of the skin due to edema• Round, oval or plaque-like• Disappears within minutes or hours**angioedema

*Localised mast cell degranulation within the skin

• Vesicles & Bullae• A well-demarcated elevation of the

superficial layers of the skin• Vesicles less than 1 cm in diameter• Bullae lager than 1 cm in diameter

• Nodules• Circumscribed elevations of the

skin that are larger than the 1 cm in diameter (deeper skin layers)

• Tumors• Masses of neoplastic origin

whether benign or malignant• May extend into the deeper

subcutaneous tissue

• Cysts• Cavities within the skin that are

lined by epithelium

• <<Secondary Lesions>>

• Comedones - dilated hair follicle which contains a pigmented impaction of lipid and keratinaceous debris “BLACK HEAD”

• Scale

• Associated with the shedding of large rafts of keratinocytes (accumulation of loose cornified fragment of the epidermis)

• Crust

• Composed of dried exudate mixtd with debris on the skin surface (serum/blood/pus)

• Exocoriation• Areas of epidermal damage

(caused by scratching, biting or rubbing)

• Ulceration• The integrity of the basal layer

(basement membrane) is destroyed• The dermis is involved and healing

is often by scar formation

• Lichenification• A thickening of the epidermis with an

accompanying hyperpigmentation in most instances (elephant skin like)

• Hyperpigmentation• Usually a consequence of melanin

excessHypopigmentation

• Loss of pigment

• Scar• Occurs when the basal layers of the

epidermis have been breached and the underlying dermis is damaged

• การตรวิจวิ�น�จฉั�ยโรคผิ�วิหน�ง

ซั�กประวิ�ต� & ตรวิจร�างกาย

Problem list ?

• Problem list?

• Pruritus• Focal / generalized/symmetrical alopecia• Crust• Hyperpigmentation• Scale• Nodule• Patch• Plaque

•Diagnostic Test• TrichogramIdentification of fur mites, adherent egg

cases, fractured ends to the hair shaft** Trichograms are not a reliable method of diagnosing, or ruling

out, ectoparasite infections

• Method

• Remove a small tuft of hair with fingers or forceps

• Laid onto trasparent adhesive tape

• Laid onto a glass slide

• Microscopic examination

• Adhesive tape stripping

• Allows direct sampling of the coat or skin surface&hair

• Observes squamous morphology, ectoparasites and micro-organisms

• Method• A commercial, clear, adhesive tape is

gently pressed onto the clipped skin surface

removed stained with Diff Quick

Laid acrossA glass slide

Laid across a glass slide

• Skin scraping

• This procedure samples the surface, the epidermis and the upper dermis

• Indication of Demodex spp., Sarcoptes scabiei and Cheyletiella spp.

• Indication of dermatophytosis (spores)

• Method

• Parasites Clip hair

Liquid paraffin is applied to the skin surface & slide

Dragged across the tensed skin repeatedly by the blade

Transfer accummulated sample to the slide

• Method • Dermatophyte

Clip hair

10%KOH applied to the skin surface & slide

Dragged across the tensed skin repeatedly by the blade

Transfer accummulated sample to the slide

Heat fixing

Stained with Lactophenol cotton blue or India ink

•Wood’s light• Indication of Microsporum canis,Microsporum distortum, Microsporum audoinii,

Trichophyton scnoenleinii

• False positive : Pseudomonas spp., Corynebacterium spp., keratin, soap, petroleum and some drugs.

• Wood lamp examination

• Fungal culture

• The scale and hair are inoculated onto a culture plate containing a medium

• Otic sampling

• Indication of Malassezia pachydermatis, bacteria and mites

• Method the sample is collected with a cotton swab

dryfixing

staining

• Impression cytology

• Used to sample cells from the surface of erosions and ulcers or from the orifices of discharging fistulae

• MedthodPressing a cleaned glass slide against the lesion

dry

Staining with Diff Quick

• Aspiration cytology

• Used to sample cells from within lymph nodes, nodules and neplasms

• Method Needle aspiration

smear

dry

Staining with Diff Quick or special stain

• Bacteria Culture

• Indication of aerobic bacteriaMethod the sample is collected with a cotton swab /

aspiration

• Intradermal skin testing

• Demonstrate the presence of allergen-specific IgG on the mast cells at the site of the intradermal injection

• Method

• Punch biopsy

• Obtain samples for histopathological examination

• Method Select site

Local anesthesia

Push biopsy punch through the skin

Remove sample & placed into 10% formaline

• Treatment• หลั�กในการร�กษาโรคผิ�วิหน�ง - ขั้จ�ดสาเหต ขั้องโรค - ปร�บสภาพขั้นแลัะผิ�วิหน�ง - บ$าร งผิ�วิหน�งแลัะขั้น

• ร%ปแบบขั้องการร�กษา• Topical treatment• Systemic therapy• Skin surgery

• THANK YOU FOR YOUR ATTENTION

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