prof. doulat rai bajaj fcps, mcps professor & chairman dept. of dermatology lumhs
TRANSCRIPT
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
How to Diagnose a skin How to Diagnose a skin DiseaseDisease
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.
How to Diagnose a skin How to Diagnose a skin DiseaseDisease
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