prof. doulat rai bajaj fcps, mcps professor & chairman dept. of dermatology lumhs

Prof. DOULAT RAI BAJAJ FCPS, MCPS

Professor & Chairman Dept. of Dermatology

LUMHS

How to Diagnose Skin Disease

History

Examination

Investigations

HistoryHistoryPresenting ComplaintsPresenting ComplaintsHistory of PresentingPresenting ComplaintsPast HistoryTravel History**Drug History** Family historyPersonal HistorySocioeconomic history etc

HISTORY of Presenting IllnessHISTORY of Presenting Illness Duration: When did it start?Duration: When did it start? Onset: sudden or gradual: varicella, P.RoseaOnset: sudden or gradual: varicella, P.Rosea Does it itch, burn or hurt?Does it itch, burn or hurt? Where on the body it did it start?Where on the body it did it start? Progress: How it spread on body; pattern of Progress: How it spread on body; pattern of

spreadspread What changes have occurred?(What changes have occurred?(evolution of lesions)evolution of lesions)

Aggravating/Relieving factorsAggravating/Relieving factors Previous treatments; its effect on lesionsPrevious treatments; its effect on lesions

How to Diagnose a skin How to Diagnose a skin DiseaseDisease

Evolution of lesions How the lesion started? What were initial signs?For Example:

1. Viral lesions start as erythematous papules & evolve into vesicles.

2. Porphyria cutanea tarda presents as vesicles on hands progressing to scars.

3. Cutaneous T cell lymphoma starts as itchy eczematous plaques papules and nodules

How to Diagnose a skin How to Diagnose a skin DiseaseDisease

Symptoms

Pruritus is an important symptom of: Atopic dermatitis Allergic contact dermatitis Biliary cirrhosis

Cutaneous fungal infections Cutaneous lymphomas

Ch.Liver/Renal disease Scabies

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Pruritus is typically NOT present in: Secondary syphilis

Leprosy

How to Diagnose a skin How to Diagnose a skin DiseaseDisease

PAIN : Skin

diseases in which pain is an Important symptom: 1. Acute viral infections

2. Leiomyoma 3. Acute vasculitic lesions 4. Neurofibromas

5. Glomus tumour

Travel HistoryTravel History

Travel to endemic areas: – Leishmaniasis

– Guinea worm

– Trypanosomiasis

Drug HistoryDrug HistorySulphonamides: Many typesSulphonamides: Many typesNSAIDs: NSAIDs: SJS syndrome, psoriasis, TEN, urticariaSJS syndrome, psoriasis, TEN, urticaria

B-blockers: psoriasis, LEB-blockers: psoriasis, LEACEIs: Psoriasis, urticaria, angioedemaACEIs: Psoriasis, urticaria, angioedemaDiuretics: xerosis, photosensitivityDiuretics: xerosis, photosensitivityMinocycline: SLE, pigmentationMinocycline: SLE, pigmentationChloroquin: bleaching of hairChloroquin: bleaching of hairLaxatives: FDELaxatives: FDEATT: LP ATT: LP

Personal History/Job/hobbiesPersonal History/Job/hobbiesACD: Cement, fertilizers, domestic chemicals,

water, farmers etcDentists: herpetic whitlowFish Tank granuloma: pond workers, fish fanciersSporotricosis and other deep fungal infections:

horticultural workers, gardeners, forest workersPhotodevelopers: Lichenoid eruptionAcne: oil workers, industry workersRadiologists, radiation workers: Skin carcinomas

Personal History contd……Personal History contd……

Contact with animals pets:–Ringworms–Orf–Erysipelas –Histoplasmosis

Family HistoryFamily History

Genodermatoses: neurofibromatosis, TSC, XP

Scabies, chickenpox, pediculosis

EXAMINATIONEXAMINATION

Note the following FeaturesNote the following Features::

SiteSite Distribution: Distribution:

Generalized: psoriasis, LP, varicella, urticaria, drug Generalized: psoriasis, LP, varicella, urticaria, drug eruptions, ADeruptions, AD

Localized: Localized: Sebhorroic dermatitis: on sebhorroic areasSebhorroic dermatitis: on sebhorroic areasScabies: genitals, finger webs, wrists, elbows, axillaeScabies: genitals, finger webs, wrists, elbows, axillae FDE: lips, genitalsFDE: lips, genitals DLE: Face, sun-exposed areasDLE: Face, sun-exposed areasPLE: Sun-exposed areasPLE: Sun-exposed areas

Examination contd….Examination contd….

Morphology of lesionsMorphology of lesions Type of lesionType of lesion: Papules, macules, patches, : Papules, macules, patches,

plaques, bulla, ulcers, erosions etcplaques, bulla, ulcers, erosions etc Size of lesionSize of lesion: : Macule (freckles) vs patch (vitiligo) Macule (freckles) vs patch (vitiligo)

Papule (warts) vs plaque (psoriasis) Papule (warts) vs plaque (psoriasis) Vesicle (viral) vs bullae Vesicle (viral) vs bullae

(pemphigus) (pemphigus) Nodule (leprosy) vs Nodule (leprosy) vs tumous (BCC)tumous (BCC)

Shape/configurationShape/configuration: annular, discoid, arcuate, : annular, discoid, arcuate, polycyclic etc.polycyclic etc.

SurfaceSurface: smooth (: smooth (keloid)keloid), rough (psoriasis) keratotic , rough (psoriasis) keratotic (warts)(warts)

Examination contdExamination contd

ColourColour: red (psoriasis, eczemas), skin coloured : red (psoriasis, eczemas), skin coloured (acne, warts, neurofibromas), violacous (LP), black (acne, warts, neurofibromas), violacous (LP), black (tatoos, melanoma), slate gray (syphilis), pale (tatoos, melanoma), slate gray (syphilis), pale (PV), milky white (vitiligo), pink (P rosea)(PV), milky white (vitiligo), pink (P rosea)

ConsistencyConsistency: : solid (warts, LP), cystic (MC, Sebaceous solid (warts, LP), cystic (MC, Sebaceous cyst), vesicular (viral), bullous (pemphigus, pemphigoid)cyst), vesicular (viral), bullous (pemphigus, pemphigoid)

MarginsMargins: well demarcated (psoriasis, erysipelas), : well demarcated (psoriasis, erysipelas), poor demarcated (cellulitis, leprosy)poor demarcated (cellulitis, leprosy)

Examination contd….Examination contd…. PatternPattern::

DiscreteDiscrete: molluscum, warts, chickenpox: molluscum, warts, chickenpox

GroupedGrouped: herpes simplex, plane warts, lichen nitidus, : herpes simplex, plane warts, lichen nitidus,

SegmentalSegmental: vitiligo, nevi: vitiligo, nevi

DematomalDematomal: herpes zoster, vitiligo: herpes zoster, vitiligo

BizarreBizarre: incontitia pigmenti, dermatitis artefacta: incontitia pigmenti, dermatitis artefacta

Scattered: Scattered: extensive: many types of eczemasextensive: many types of eczemas

SymmetrySymmetry: Symmetrical (psorisis, AD, Discoid eczema), : Symmetrical (psorisis, AD, Discoid eczema),

Asymmetical( tinea, TB)Asymmetical( tinea, TB)

LinearLinear: :

How to Diagnose a How to Diagnose a skin Diseaseskin Disease

Guttate psoriasis: discrete lesions on chest

How to Diagnose a skin How to Diagnose a skin DiseaseDisease

Bizarre pattern: Verrucous epidermal nevus

linearlinear

Occur due to involvement of dermatome, blood vessels or lymphatics.

May be developmental origin.May follow Blashko’s lines.Koebner phenomenon.

Examination contd…Examination contd…

Shape/Configuration– Annular (centre clear): Tinea, LP, psoriasis– Discoid (centre filled) : discoid eczema,

psoriasis, UV– Arcuate (incomplete circles): urticaria– Serpiginous (snake): cutaneous larva migrans– Reticulate: livido reticularis, cutis mormorata– Polycyclic: psoriasis– Target: EM

How to Diagnose a skin How to Diagnose a skin DiseaseDiseaseArcuate

:An arc like or moon shaped arrangement. e.g. Stevens Jhonson syndrome

How to Diagnose a How to Diagnose a skin Diseaseskin Disease

Arcuate lesions: Stevens Johnson Syndrome

How to Diagnose a skin How to Diagnose a skin DiseaseDisease

Satellite LesionsCandidiasisleishmaniasis

How to Diagnose a skin DiseaseHow to Diagnose a skin Disease Satellite lesions: candidiasis

How to Diagnose a skin How to Diagnose a skin DiseaseDisease

Location/Site of lesion

Psoriasis: Extensor areas, scalp & nails Vasculitis: Feet, lower limbs, buttocks E. Nodosum, P.gangrenosum: legs, thighs DLE: face, nose, pinnae, neck SLE: malar area of face, bridge of nose Herpes simplex: near muco-cutanous junction Herpes zoster: in zosteriform distribution

How to Diagnose a skin How to Diagnose a skin DiseaseDisease Secondary syphilis: trunk, palms & soles Pityriasis versicolour: Trunk, back, arms Atopic dermatitis: cheeks, wrists, flexures Porphyria: face, dorsa of hands & feet Lichen Planus: wrists, lumbar regions, oral

mucosa Pemphigus Vulgaris: Head and upper trunk Adenoma sebaceum of TSC: around nose Stevens Johnson Synd: Acral parts and

mucosal surfaces

How to Diagnose a skin How to Diagnose a skin DiseaseDisease

Trans location of lesionCarry the lesion to its typical site in your

mind.This concept is helpful when diseases

present on atypical sites.

Palpation of LesionsPalpation of Lesions

Simple palpation: to determine texture

Blunt pressure: to detect oedema, capillary refill, identify

the dermal defect in anetoderma.

Linear or shearing pressure: to elicit dermographism, or

Nikolsky’s sign in pemphigus

Squeezing or pinching: to determine depth

& consistency of lesions: pinching in scleroderma,

squeezing dermatofibroma lesion produces dimpling

Rubbing: release chemicals, e.g. rubbing a mastocytoma

causes urtication and a flare due to histamine release

(Darier’s sign)

Scratching and picking: scratching scale in psoriasis

makes scale appear more silver by introducing air–

keratin interfaces; more vigorous scratching produce

small bleeding points (Auspitz’s sign)

Investigations Investigations

1. Diascopy

2. Wood’s light

3. Tzanck smear

4. Dermoscopy

5. Confocal laser scanning microscopy

6. Biopsy

Diascopy Diascopy

Gentle pressure on lesion with a glass slide.Lupus vulgaris: apple jelly nodulesNevus anaemicusVitiligoSpider neviErythema vs purpura

Wood’s LightWood’s Light

This is a source of ultraviolet light from which virtually all visible rays are excluded by a Wood’s (nickel oxide) filter

Uses:

1. Tinea capitis: green flourescence

2. Erythrasma: coral pink

3. Pityriasis versicolor: yellow

4. Scabies: put flourescin on lesion to visualize burrow

5. Porphyrias: teeth, urine, faeces and serum flouresence

6. Ash leaf macules in tuberous sclerosis

Dermoscopy Dermoscopy

Also known as epiluminescence microscopy, is an extension of the simple magnification. Dermoscopes have built-in illumination.

The oil is applied on the lesion to enhance visibility of subcorneal structures. The lesion examined with dermoscopes.

The technique is mainly used in the diagnosis of doubtful pigmented lesions

Confocal laser scanning microscopy

Digital Scanning Photography

SITESITE

Face: Acne vulgaris. lupus vulgaris DLE Melasma Pitriasis alba. Tuberous sclerosis. BCC/SCC Trunk: Tinea. Pitriasis rosea. Pitriasis versicolor. Acne vulgaris Psoriasis.

LIMBSLIMBS

Pyoderma gangrenosum.Erythema nodosum.Erythema induratum.

Macules: Macules:

Pinpoint: lichen nitidusLess than 0.5 cm: MaculeMore than 0.5 cm: Patch

TYPE & SHAPETYPE & SHAPE

Primary/secondary. Flat.Raised.Raised & fluid containing.

PRIMARY RAISED LESIONSPRIMARY RAISED LESIONS

Papule: less than 0.5 cm

Plaque: more than 0.5 cm

Nodule: larger with three dimensions

PapulePapule

Less than 5mm.round/oval/polygonal.Colour: red, pink, purple, pigmented.

How to Diagnose a skin How to Diagnose a skin DiseaseDiseasePapule/Plaque:

–Dome shaped: Psoriasis, Lichen planus

–Pointed: Keratosis pilaris, PRP

–Umblicated: Viral infections

–Well circumscribed plaques: Psoriasis

–Irregular plaques: Lupus vulgaris, Shagreen patches

–Targetetoid: Stevens Jhonson synd

PlaquePlaque

RaisedMore than 0.5cm.

NoduleNodule

circumscribed solid,palpable,Deep & indurated.More than 0.5 cm.

PRIMARY RAISED & FLUID PRIMARY RAISED & FLUID CONTAINING LESIONSCONTAINING LESIONSPustule.Vesicle. Cyst.Bullae.Wheal.

PustulesPustules

Pus containing.Circumscribed. Less than 1cm.

VesicleVesicle

Less than 1cm.Containing clear fluid.

CystCyst

More than 0.5cm.May contain pus, blood, sabecous

secretions, mucous.

Bulla (blister)Bulla (blister)

Vesicle more than 0.5cm.May be tense/tender.

WhealWheal

Transient edematous elevation.Pink to pale in colour.Cause by oedema of dermis &

capillary dilation.

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Vesicular Lesions–All viral infections present as acute

vesicular lesions: e.g. Herpes Simplex, Herpes zoster, Moll.Contagiosum

–Autoimmune blistering diseases present as bullous eruption

–Acute irritant contact dermatitis

How to Diagnose a skin How to Diagnose a skin DiseaseDisease

Purpuric LesionsLeukocytoclastic vasculitisHenoch Schonlein purpuraMeningococcal meningococcemiaDrugs

How to Diagnose a skin How to Diagnose a skin DiseaseDisease

Henoch Schonlein purpura: palpabe purpura on buttocks

SECONDARY LESIONSSECONDARY LESIONS..

Crust.Excoriation.Lichenification.Necrosis.Scar.Scaling.Exfoliation.Fissure.

Keratoderma.Vegitations.Erosions.Ulcer.Atrophy.Sclerosis.

CrustCrust

Dried exudate,May be serous, prulent,

haemorrhagic.

ExcoriationExcoriation

Haemorrhagic excavation resulting from scratching.

LichenificationLichenification

Thickening of skin with exagerated skin creases.

NecrosisNecrosis

Death of skin tissue usually black in colour.

ScarScar

Final stage of healing of destructive process.

Involve deeper dermis.White, smooth, shiny.

ScalingScaling

Desquamated horney flakes prduced due to abnormal keratinization.

May dry, greasy.

ExfoliationExfoliation

Splitting off of stratum corneum in fine scales or sheets.

FissureFissure

Linear split or gap in skin surface.Usually painful.

KeratodermaKeratoderma

Horney thickening of stratum corneum.

May be congenital abnormality, or as simple mechanical stimulation.

VegitationsVegitations

A growth Of pathological tissueConsisting of multiple close set,

papillomatous masses.

ErosionErosion

Partial break in the epidermis.Heal with out scarring unless

secondary infected.

UlcerUlcer

A full thickness loss of skin .Heal by scarring.

AtrophyAtrophy

Thinning & transparency of skin by diminution of epidermis, dermis or both.

Wrinkling & translucensy of skin with Loss of skin marking.

SclerosisSclerosis

Circumscribed or diffuse hadening or induration of the skin

Occur as a result of dermal or subcutenous oedema cellular infiltration or collagen proliferration.

SurfaceSurface

Rough,eg seborrheic warts.Smooth eg nelanocytic naevus. Flat topped eg lichen planus.Pointed eg miliaria rubra.Mamilliated eg compound naevus.Dome shape, umblicatted eg

molluscum contagiosum.

ColourColour

Pink in EczemaRed in PsoriasisBrown in Pityriasis versiclor. Purple Papules in lichen planus.Red papules in scabies.

ConsistencyConsistency

Firm in DermatofibromaSoft in Dermal mole.Hard in secondary deposites.Teethered in Scleroderma.

MarginsMargins

Discrete as in PsoriasisIndistinct as in Eczema.Activety more peripherally, with

central healing as in tinea, Lichen planus.

Raised & rolled in BCCIrregular in malignant melanoma.

Annular patternAnnular pattern

Can be maular, papular, nodular.

Reticular arrangementReticular arrangement

Net like arrangementLivedo reticularisCutis marmorataErythema ab igneOral lesion in lichen planus