Examination of Skin

Skin complaints are common in clinical exams and everyday practices.
Skin cancers are increasing in prevalence and if detected early, treatment can be curative.
cutaneous signs can also be a vital in identifying systemic diseases.
With a structured examination technique and a little knowledge of terminology, skin signs can classified systematically.

1. EXAMINATION OF SKIN

2. THE SKIN HISTORY CHIEF COMPLAINT HISTORY OF PRESENT ILLNESS ( onset,course,intermittent or contagious-always present or does it come and go)? PAST MEDICAL HISTORY- medications,allergies . FAMILY HISTORY-psoriasis, infestations,infections . PSYCHO-SOCIAL HISTORY–personal habits,exposures,health -related behaviours. SOCIALHISTORY-occupation REVIEW OF SYSTEMS-involves performing a brief screen for symptoms in other body systems.

3. Q1- When did it start? Q2-Does it itch,burn or hurt? Q3-Associated symptoms? Q4-Is this the first episode? Q5-Where on the body did it start (location)? Q6-How has it spread ? Q7-How have individual lesions changed? Q8-Provoking /aggravating factors? Q9-Previous treatments and response?

4. EXAMINATION AIDES /ESSENTIAL ELEMENTS FOR THE SKIN EXAM Ruler :-> Accurately records the size of a lesion on successive examination. Lighting Pen light Gloves Magnifying glass Woods lamp :->(long wavelength U.V light) to examine if a lesion is hypo or depigmented or to see if a fungal infection fluoresces.

5. Dermatoscopes :-> Magnify the lesions with a hand lens or using epiluminescence microscopy ( using a hand lens with magnification & lighting built into better visualize lesions. Avoid LED lights. Penlight :-> Is used for slide lighting. Detects atrophy & fine wrinkling Distinguishes flat from raised lesions whether lesions are solid or fluid filed. Diascopy :-> Press a transparent firm object such as a glass slide against a lesion to determine if an erythematous lesion blanches (loses red color ),lesions remains red suggests – purpura .

6. DIASCOPY

7. WOOD’S LAMP

8. THE TOTAL BODY SKIN EXAM INCLUDES INSPECTION OF THE ENTIRE SKIN SURFACE INCLUDING- The scalp , hair,and nails The mucous membranes of the mouth ,eyes ,anus and genitals. HISTORY OF HAIRS AND NAILS- Timing of onset Associated symptoms Nutritions - iron deficiency (spoon nails),zinc deficiency(beau’s lines) elevating /Aggravating Treatments Exposures

9. EXAMINATION Inspection :-> Colour i.e dark purple( purpura ) Distribution( symmetry)-suggesting a external cause i.e. Infection,trauma etc. Do lesions leave pigment change (increased or decreased) or scars? Shape and size Border Well demarcated or indistinct. Ask the patient to indicate early and late lesions Decide what is primary or secondary & how lesions evolves or spread. Any particular pattern – diffuse,linear,grouped or scattered.

10. COLOR TYPES IN DIFFERENT LESIONS RED SKIN – erythema , cutaneous tumors ORANGE SKIN- hypercarotenemia YELLOW SKIN – jaundice,xanthelasmas and xanthomas and pseudoxanthoma elasticum . GREEN FINGERNAILS- pseudomonas aeruginosa infection. VIOLET SKIN – cutaneous hemorrhage or vasculities . A LILIAC color of the eyelids is characteristics of dermatomyositis . SHADES OF BLUE,SILVER AND GRAY- from deposition of drugs ormetals in skin.Ischemic skin appears purple to gray in color . BLACK SKIN- malenoma,or by infections i.e. meningococcemia .

11. Specifies of rash description----  Excoriation- Look for linear scratch works (excoriations) indicative of itching ( pruritus ) Ulcer/erosion- Is the skin eroded (involves epidermis and heals without a scar) or ulcerated ( extendes upto dermis and heals with scaring)? Weeping –if something is oozing out from the lesion. Crusting (when serum,blood,pus dries on skin surface) , Scale, hyperkeratosis. Blood vessels - Suggesting skin atrophy or superficial vasculature Odour- Foul smelling ulcers may be infected with anaerobes or pseudomonas aeruginosa some rashes smell unplesant Ex. Darier disease.

12. PALPATION- -Tenderness -In the elderly people,patients taking systemic steroids or patients with rheumatoid arthritis ,the skin may exceptionally fragile. SURFACE TEXTURE- The surface texture of lesions can be assessed by running a finger over the top of a lesion to feel if the skin is smooth or rough. SCALING - If scaling is not easily visible,lightly scraps a lesion with your fingernail scaling. E L EVATION- Palpable/flat. If SKIN IS RED –check blanching with light pressure. - purpura (non blanching) is caused by leakage of blood into the perivascular dermal tissues. SKIN THICKNESS AND DEPTH OF INVOLVEMENT – ATROPHY ( TISSUE LOSS) WITH WRINKLING OR DIMPLING (LOSS OF FAT) TETHERING- Gently pinch the skin or try to pick up lumps between finger and thumb to assess depth .Is there any tethering to lying tissue? CHECK FOR ASSOCIATED SIGNS – FEEL TEMPERATURE -INFLAMED SKIN - CELLULITIS –HOT -POORLY PERFUSED-COLD SKIN MOBILITY

13. S EQUENCE- REGIONAL SYSTEM THREE CATEGORIES OF OBSERVATION- Anatomic distribution of the lesion.(location on body) Configuration of groups of lesions.(how lesions are arranged or related to each other) The morphology of individual lesions.

14. DIAGNOSTIC METHODS BIOPSY LABORATORY STUDIES

15. Primary skin lesions 1 . MACULE 7.BULLA 13.ECHYMOSIS 2.PAPULE 8.POSTULE 14-HEMATOMA 3.PLAQUE 9.WHEAL 15.POIKILODERMA 4.NODULE 10.TELANGICTASIA 16-ERYTHEMA 5.PAPILLOMA 11.PETECHIAE 17-BURROW 6.VESICLE 12.PURPURA 18-COMEDO

16. EXAMPLES OF DIFFERENT SKIN LESIONS MACULES- freckles (small brown spots on skin),flat moles,tattoos,and the rashes of rickettsial infections,rubella,measles (can also have pustules and plaques) and some allergic drug eruptions. PAPULES- warts,some lesions of acne,skin cancer,lichen planus,actinic keratoses (due to sun exposure). PLAQUES- psoriasis and granuloma annulare . NODULES- cysts,lipomas and fibromas . VESICLES- herpes infection,acute allergic contact dermatitis and some autoimmune blistering disorders (e.g. Dermatities herpetiformis ) BULLAE- burns , bites,allergic contact dermatities and durg reaction. PUSTULES- In Bacterial infections , pustular psorasis,folliculitis .

17. Rapid Evolution In Chickenpox

18. Dengue fever rash

19. Urticaria

20. Pustule

21. Bullae

22. Psoriasis Plaque

23. Papule

24. Labial melanotic macule

25. SECONDARY SKIN LESIONS 1-SCALE 7-ULCER 2-CRUST 8-SINUS 3-EXCORIATION 9-SCAR 4-LICHENIFICATION 10-KELOID 5-FISSURE 11-ATROPHY 6-EROSION 12-STRIA

26. PRIMARY AND SECONDARY LEISONS RAISED FLAT DEPRESSED FLUID- FILLED VASCULAR Papule Macule EROSION Plaque patch ULCER VESICLE ECCHYMOSES Nodule ATROPHY BULLA Tumor SINUS PUSTULE Wheal STRIA ABSCESS Burrow Scar

27. IDENTIFYING PRIMARY AND SECONDARY SKIN LESION PRIMARY LESIONS- BULLA- a vesicles greater than 5 mm in diameter. CYST-An elevated ,circumscribed area of the skin filled with liquid or semisolid fluid. MACULE -a flat,circumscribed area;can be brown , red,white or tan. NODULE-an elevated,firm,circumscribed,and palpable area greater than 5mm in diameter,can involve all skin layers. PAPULE - an elevated,palpable,firm,circumscribed area generally less than 5mm in diamter . PLAQUE- an elevated ,flat- topped,firm,rough,superficial papule greater than 2cm in diameter; VESICLE -an elevated , circumscribed,superficial,fluid -filled blister less than 5mm in diameter WHEAL-an elevated,irregular shaped area of cutaneous edema;wheals are solid,transient,and changeable,with a variable diameter;can be red,pale pink,white . purpura - a rash of purple spots due to leakage of blood from small blood vessels. PETECHIAE -tiny round ,brown purple spots due to bleeding under the skin ,may be in small area or widespread. ECCHYMOSIS - a flat ,blue or purple patch measuring 1cm in diameter.

28. SECONDARY LESIONS CRUST-A slightly elevated area of variable size;consists of dried serum,blood , or purulent exudate . EXCORIATION- linear scratches that may or may not be denuded. LICHENIFICATION- rough,thickened epidermis;accentuated skin markings caused by rubbing or scratching. SCALE-heaped-up keratinized cells;thick or thin;dry or oily;variable size,can be white or tan.

29. HYPERPIGMENTED MACULES

30. THREE HYPOPIGMENTED MACULES ON LOWER BACK

31. PURPURA

32. INFANT WITH ECCHYMOSES

33. VESICLES

34. VESICLES

35. DIAGNOSIS AND MANAGEMENT OF TVAK VIKARAS IN AYURVEDA Diagnosis of tvak roga Based on the clinical features. Based on the Dosha involved. Examination of the lesions. Complete History of illness Past history Svatantra and paratantra (eczema due to vericose veins)

36. PHYSICAL EXAMINATION OF THE SKIN A. Initial clinical Impression – Does the patient look ill,i.e . Anxious,calm,angry etc. B. Complete skin Examination (4 components)- HEAD TO TOE EXAMINATION Skin Hair Nails Mucous membranes C. Cardinal features of examination (4 Cardinal features)- 1 . Type of Lesion-primary vs secondary 2. Shape of lesion 3. Arrangement of lesions] 4. Distribution of lesions D .Characteristics of individual lesions

37. CLINICAL FEATURES Vata Pradhana Pith Pradhana KaphaPradhana Parushya Daha shvetata Shosha Raga Saityata Toda paka kandu Shoola visragandha sthairya Sankocha kleda utseda Ayama angapatana gourava Harsh sneha Shyava-arunatva kleda jantubhiabhibhakshana