Skin Disorders

Bacterial Infections• Bacteria are single celled micro-organisms

– Spherical, doublets, and spirochetes• Staphylococcus

– Gram positive bacteria that appears in clumps in skin and upper respiratory tract

• Streptococcus– Chain bacteria often associated with systemic disease and skin

infections• Bacillus

– Spore forming, aerobic, and occasionally mobile– Can cause systemic damage

• Impetigo Contagiosa– Etiology

• Caused by A-beta-hemolytic streptococci, S aureus or combination of these bacteria

• Spread through close contact– Signs and Symptoms

• Mild itching and soreness followed by eruption of small vesicles and pustules that rupture and crust

• Generally develops in body folds that are subject to friction– Management

• Cleansing and topical antibacterial agents• Systemic antibiotics

• Furunculosis (Boils)– Etiology

• Infection of hair follicle that results in pustule formation

• Generally the result of a staphy. Infection

• Usually, the cause is bacteria such as staphylococci that are present on the skin.

– Signs and Symptoms• Pustule that becomes reddened and enlarged as well

as hard from internal pressure• Pain and tenderness increase with pressure• Most will mature and rupture

– Management• Care involves protection from additional irritation• Referral to physician for antibiotics• Keep athlete from contact with other team members

while boil is draining

• Carbuncle

• A carbuncle is a skin infection that often involves a group of hair follicles. The infected material forms a lump, which occurs deep in the skin and may contain pus.

• most commonly Staphylococcus aureus, or Streptococcus pyogenes,

– Etiology• Similar in terms of early stage development as furuncles

– Signs and Symptoms• Larger and deeper than furuncle and has several

openings in the skin• May produce fever and elevation of WBC count• Starts hard and red and over a few days emerges into a

lesion that discharges yellowish pus– Management

• Surgical drainage combined with the administration of antibiotics

• Warm compress is applied to promote circulation

• Folliculitis – Etiology

• Inflammation of hair follicle

• Caused by non-infectious or infectious agents

• Moist warm environment and mechanical occlusion contribute to condition

• Psuedofolliculitis (PFB)

– Signs and Symptoms• Redness around follicle that is followed by

development of papule or pustule at the hair follicle

• Followed by development of crust that sloughs off with the hair

• Deeper infection may cause scarring and alopecia in that area

– Management• Management is much like impetigo• Moist heat is used to increase circulation• Antibiotics can also be used depending on the

condition

• Hidradenitis Suppurativa : a chronic suppurative inflammatory disease of the apocrine sweat glands

Etiology• Primary inflammation event of the hair follicle resulting in

secondary blockage of the apocrine gland• Post-pubescent individuals are more likely to exhibit HS.[8]

• Plugged apocrine (sweat) gland or hair follicle• Excessive sweating• Sometimes linked with other autoimmune conditions[9][10]

• Androgen dysfunction• Genetic disorders that alter cell structure• Patients with more advanced cases may find exercise intolerably

painful, which may increase the rate of obesity among sufferers.

– Signs and Symptoms• Begins as small papule that can develop into deep

dermal inflammation– Management

• Avoid use of antiperspirants, deodorants and shaving creams

• Use medicated soaps and systemic antibiotics

• Acne Vulgaris– Etiology

• Inflammatory disease of the hair follicle and the sebaceous glands

• Sex hormones may contribute– Signs and Symptoms

• Present with whiteheads, blackheads, flesh or red colored papules, pustules or cysts

• If chronic and deep = may scar• Psychological impact

– Management• Topical and systemic agents used to treat acne• Mild soaps are recommended

• Paronychia and Onychia • An infection that develops along the edge of

the fingernail or toenail is called a paronychia

– Etiology• Caused by staph, strep and or fungal organisms that

accompany contamination of open wounds or hangnails • Damage to cuticle puts finger at risk

– Signs and Symptoms• Rapid onset; painful with bright red swelling of

proximal and lateral fold of nail• Accumulation of purulent material w/in nail fold

– Management• Soak finger or toe in hot solution of Epsom salt 3 times

daily• Topical antibiotics, systemic antibiotics if severe• May require pus removal through skin incision

• Tetanus Infection – Etiology

• Acute infection of the CNS caused by tetanus bacillus

• Bacteria enters through the blood and open wounds

– Signs and Symptoms• Stiffness of the jaw and muscles of the neck• Muscles of facial expression produce contortion

and become painful• Fever may become markedly elevated

– Management• Treat in intensive care unit• Childhood immunization

• Connective tissue • dermis and

subcutaneous tissues• acute spreading• pain, erythema,

edema, and warmth

Cellulitis ： Characteristic

• trauma or surgery• causing a lesion in the skin• may have no discernible dermal injury• develops over a period of several days

Cellulitis ： History

The affected area• Warmth• Erythema• Edema• TendernessThe proximal to the area• Ascending lymphangitis• lymphadenopathy

Cellulitis ： Signs & Symptoms

• Significant erythema • An eroded area near the

center• Irregular margins but

not raised • An ulcerated area in the

center • Painful and warm to the

touch

Severe Cellulitis ：

• normal – group A streptococci & Staphylococcus aureus

• Infants– group B streptococci

• Immunocompromised– Pneumococcus gram-negative rods or fungi

• Wounds– Aeromonas hydrophila, gram-negative rod

Etiology ： Microorganism

Obesity

Diabetes

Poor hygiene condition

Intravenous drugs

Immunodeficiency

High Risk Factors

• Bacteremia• Local abscess• Superinfection with gram-negative organisms• Lymphangitis• Thrombophlebitis• Facial cellulitis in children (meningitis in 8%)• Gas gangrene(amputation & mortality in 25%)

Cellulitis ： Complications

• Escherichia coli in nephrotic syndrome

• Cellulitis of the lower extremities in geriatric

patients (thrombophlebitis)

• Pseudomonads in immunocompromised children

Cellulitis ： Special Concerns

Antibiotics:• penicillinase-resistant synthetic penicillin• first-generation cephalosporin• clindamycin• metronidazole

Management ：

• caused by group A beta-hemolytic streptococci• Involving dermis and lymphatics• more superficial subcutaneous infection than

cellulitis• characterized by intense erythema, induration, and

a sharply demarcated border,

Erysipelas ： Characteristic

70-80% in lower extremities

Erysipelas ： Characteristic

5-20% in face

Erysipelas ： Characteristic

• Abrupt onset of illness (Painful rash)• Initial fever and chills (1-2 days later)• Muscle and joint pain• Nausea• Headache• Systemic infectious manifestations • Skin discomfort

Erysipelas ： History

• Fever• Dermatologic signs

• Painful, erythematous, and edematous rash• Sharply-raised border with abrupt demarcation from

healthy adjacent skin• Lymphangitis

• Erythema (irregular extensions)• Desquamation• Vesicles• Lymphadenopathy

Erysipelas ： Signs & Symptoms

Sharply-raised border with abrupt demarcation from healthy adjacent skin

Erysipelas ： Signs & Symptoms

• Painful• Erythematous• Edematous

rash

Erysipelas ： Signs & Symptoms

• Group A streptococci (the most)

• Group G, C, B streptococci (less)

• Staphylococci (rarely)

Etiology ： Microorganism

• Antibiotics (as soon as possible)• Penicillin• Erythromycin• Cephalexin

• Symptomatic treatment• Antipyretic• Analgesics

• Hydration (oral intake if possible)• Cold compresses

Management ：

• Gangrene & Amputation• Bacteremia & Sepsis• Scarlet fever• Pneumonia• Abscess• Embolism• Meningitis• Death

Complications ：

• The infection of lymph nodes (glands)

• usually associated with the site of the

underlying infection, tumor, inflammation

• common result of a cellulitis or other

bacteria infection

Lymphadenitis ： Characteristic

• swollen, tender, hard nodes

• smooth or irregular to touch

• or soft and "rubbery" (fluctuant) if an abscess has formed

• the skin over a node may be reddened and hot

Lymphadenitis ： Signs & Symptoms

• Infection of lymph vessels/channels• Commonly results from cellulitis or abscess in the

skin or soft tissues• A progressing infection raising spread of bacteria

to the bloodstream– life-threatening infections 

• Be confused with a clot in a vein (thrombophlebitis)

Lymphangitis ： Characteristic

• red streaks – from infected area to the armpit or groin

• throbbing pain– along the affected area

• lymph nodes • fever and chills • malaise,loss of appetite, headache, muscle aches

Lymphangitis ： Signs & Symptoms

• Physical examination

• Biopsy (LN)

• Blood culture

Lymphadenitis and lymphangitis may spread within

hours, spreading to the bloodstream may be fatal.

Diagnosis ：

Treatment should begin promptly

• Specific antibiotics

• Surgical drainage

• Hot moist compresses

Management ：

Necrotizing Fasciitis

It is a progressive, rapidly spreading, inflammatory infection located in the deep fascia with 2ry necrosis of the subcutaneous tissue.

Risk Factors

• Immunocompression illnesses e.g.: DM, Cancer, alcoholism, vascular

insufficiency, organ transplant, HIV or neutropenia.

• Trauma or foreign bodies in surgical wound.

• Idiopathic as scrotal or penile necrotizing fasciitis.

Causative Agents

It is a mixed microbial flora: # microaerophilic streptococci. # staphylococci. # aerobic gram –ve # anaerobes ( peptostreptococi – bacteroids)

Pathophysiology

Mortality & Morbidity

The overall morbidity & mortality is 70 – 80%

Fournier’s gangrene has a reported mortality as high as 75%

Sex: Male : Female 3:1

Age: * the mean age is 38 to 44 years. * pediatric cases are rare but reported from countries where poor hygiene in.

Clinical Features

Symptoms: *sudden onset of pain and swelling at the

site of trauma or recent surgery. *in some cases, the symptoms may begin

at the site distant from the initial traumatic insult.

*Fournier's gangrene begin with pain and itching of the scrotal skin.

Clinical Features (cont.)Sings: * pt. appears moderately to severely toxic (but sometimes might looks

well) * typically, erythema that quickly spread over a course of hours to days. * the redness quickly spread & the margin of infection move out into

normal skin without being raised nor sharply demarcated. * anesthesia

# Note: *I.M. injections & I.V. infusions may lead to necrotizing fasciitis. *minors insect bites may set the stage for necrotizing infections.

Investigations

Lab: CBC, U&E, Glu, Creatinine, Blood & tissue cultures, Urine analysis, & ABG.

Investigations (cont.) Imaging Studies:

# X-ray gas in the subcutaneous fascia planes. ?? D.D. of subcutaneous gas in a radiograph.

# C.T. demonstrating necrosis with asymmetric fascial thickening & gas in the tissues.

# MRI.

Investigations (cont.) Microbiology:

Gram stain & wound culture

Procedures: Biopsy is the best method to use to obtain proper cultures for micro-organisms.

Emergency Department care

• A

• B

• C

• D

Management

If streptococci are the identified major pathogens, the D.O.C is Penicillin-G with clindamycin as an alternative.

To ensure adequate treatment, we have to cover aerobic & anaerobic bacteria.

The anaerobic coverage can be provided by Metronidazole or 3rd generation cephalosporin's.

Management (cont.)

Gentamicine combined with clindamycine or chloramphenicol has been reported as a standard coverage.

Ampicilline may be added to the basic regimen to treat enterococci if suspected by gram stain.

Further In-Patient Care

• Surgical debridment.

• Fasciotomy.

• H.B.O.

Complications

• Renal Failure.

• Septic Shock with cardiovascular collapse.

• Scarring with cosmetic deformity.

Microbiological emergencyCaused by exotoxin-producing Clostridium perfringensusually after direct inoculation of contaminated, ischaemic wound

Gas Gangrene

Myonecrosis, gas production, sepsis Rapid onset and toxaemia / shock

Crepitus, brawny oedemaFoul-smelling discharge, brown skin discoloration, bullae, May advance 1“ per hour!Disproportionate pain.Mortality > 25%

Fungal Infections

• Group of organisms that include yeast and molds which are usually not pathogenic

• Grow best in unsanitary conditions with warmth, moisture and darkness

• Infections generally occur in keratinized tissue found in hair, nails and stratum corneum

• Dermatophytes (Ringworm fungi)– Cause of most skin, nail and hair fungal

infections

• Tinea of the Scalp (tinea capitis)– Signs and Symptoms

• Ringworm of the scalp begins as a small papule that spreads peripherally

• Appears as small grayish scales resulting in scattered balding

• Easily spread through close physical contact– Management

• Topical creams and shampoos are ineffective in treating fungus in hair shaft

• Systemic antifungal agents are replacing older agents due to increased resistance

• Some topical agents are used in conjunction

• Tinea of the Body (tinea corporis)– Signs and

Symptoms• Commonly involve

extremities and trunk

• Itchy red-brown scaling annular plaque that expands peripherally

– Management• Topical antifungal

cream

• Tinea of the Nail (tinea unguium/ onchomycosis)– Signs and Symptoms

• Fungal infection of the nail -- found commonly in those engaged in water sports or who have chronic athlete’s foot

• Nail becomes thick, brittle and separated from its bed– Management

• Some topical antifungal agents have proved useful • Systemic medications are most effective• Surgical removal of nail may be necessary if extremely

infected

• Tinea of the Groin (tinea cruris)– Etiology

• Symmetric red-brown scaling plaque with snake-like border

– Signs and Symptoms

• Mild to moderate itching

– Management• Treat until cured• Will respond to many of the non-prescription

medications• Medications that mask symptoms should be avoided• Failure to respond to normal management may

suggest a non-fungal problem (such as bacteria) and should be referred to a physician

• May require additional topical medications and oral prescriptions

• Athlete’s Foot (tinea pedis)– Etiology

• Most common form of superficial fungal infection• Tricophyton species are most common cause of

athlete’s foot• Webs of toes may become infected by a

combination of yeast and dermatophytes– Signs and Symptoms

• Extreme itching on soles of feet, between and on top of toes

• Appears as dry scaling patch or inflammatory scaling red papules forming larger plaques

• May develop secondary infection from itching and bacteria

– Management• Topical antifungal agents and good foot hygiene

• Candidiasis (Moniliasis)– Etiology

• Yeast-like fungus that can produce skin, mucous membrane and internal infections

• Ideal environment includes hot humid weather, tight clothing, and poor hygiene

– Signs and Symptom• Infections w/in body folds• Presents as beefy red patches and possible satellite

pustules• White, macerated border may surround the red area;

deep painful fissures may develop at skin creases– Management

• Maintain dry area• Use antifungal agents to clear infection

• Tinea Versicolor– Etiology

• Caused by a yeast• Appears commonly in areas in which sebaceous glands actively

secrete body oils– Signs and Symptoms

• Fungus produces multiple, small, circular macules that are pink, brown, or white

• Commonly occur on chest, abdomen, and neck• Do not tan when exposed to sun and usually are asymptomatic

– Management• Straightforward treatment - recurrences are common• Use selenium shampoo (Selsun) and topical econazole nitrate (or

something similar)• When microorganism has been eradicated, re-pigmentation of the

area will occur

Viral Infections

• Ultramicroscopic organisms that require host cells to complete their life cycle– May stimulate cell chemically to produce more

virus until host cell dies– Lies within bud-like structure that does not

damage cell or virus, w/out causing infection• A number of skin infections are caused by

viruses

• Herpes Simplex Labialis, Gladiatorum, and Herpes Zoster– Etiology

• Highly contagious and is usually transmitted directly through a lesion in the skin or mucous membrane

• Resides in sensory nerve neurilemmal sheath following initial outbreak

• Recurrent attacks stimulated by sunlight, emotional disturbances, illness, fatigue, or infection

• Type I vs. Type II– Signs and Symptoms

• Early indication = tingling or hypersensitivity in an infected area 24 hours prior to appearance of lesions

• Local swelling followed by outbreak of vesicles• Athlete may feel ill w/ headache, sore throat, swollen

lymph glands and pain in area of lesions

– Signs and Symptoms (continued)• Vesicles generally rupture in 1-3 days spilling serous

material• Heal in generally 10-14 days• If an athlete has an outbreak they should be

disqualified from competition due to contagious nature of condition

– Management• Herpes simplex lesions are self limiting - reduce pain

and promote early healing• Use of antiviral drugs can reduce recurrence and

shorten course of outbreak– Complications

• Can lead to secondary infection

Verruca Virus and Warts

• Varied of forms exist– verruca plana (flat wart), verruca plantaris (plantar

wart), and condyloma acuminatum (venereal wart)• Different types of human papilloma virus have

been identified– Uses epidermal layer of skin to reproduce and

growth• Wart enters through lesion in skin

• Common Wart– Signs and Symptoms

• Small, round, elevated lesion with rough dry surfaces

• Painful if pressure is applied• May be subject to secondary bacterial

infection– Management

• If vulnerable, they should be protected until treated by a physician

• Use of electrocautery, topical salicylic acid or liquid nitrogen are common means of managing this condition

• Plantar Warts– Etiology

• Spread through papilloma virus– Signs and Symptoms

• Located on sole of foot, on or adjacent to areas of abnormal weight bearing

• Areas of excessive epidermal thickening• Discomfort, point tenderness• Hemorrhagic puncta (black seeds)

– Management• While in competition, protect and prevent spreading• Pair away callus and apply keratolytic • Following season, wart can be removed by freezing it or

by electrodessication (maintain protection until removal)

• Molluscum Contagiosum – Etiology

• Poxvirus infection which is more contagious than warts (especially during direct body contact)

– Signs and Symptoms• Small, flesh or red colored, smooth-domed papules

with central umbilication– Management

• Physician referral is necessary• Cleansing and destructive procedure (counterirritant

such as cantharidin, surgical removal or cryosurgery)

Allergic, Thermal, and Chemical Skin Reactions

• Allergies are immunologically mediate responses to molecules in dyes and proteins against which the body’s immune system is sensitized

• Allergens may be food, drugs, clothing, dusts, pollens, plants, animals, heat, cold, or light

• The skin will reflect an allergy in many ways such as reddening and swelling of the tissue, uticaria or hives, burning or itching

• ATC’s must recognize gross signs of allergic responses and be prepared to remove allergens and treat topically or systemically with antipruritic agents

• Contact Dermatitis (allergic and irritant)– Etiology

• Plants are the most common cause (poison ivy, poison oak, sumac, ragweed, primrose)

• Topical medications• Chemicals found in fragrances and preservatives of soaps, detergents

– Signs and Symptoms• Onset may range from 1 day to 1 week• Redness, swelling, formation of vesicles that ooze fluid and form crust,

constant itching• May change from redness and blistering to erythematous scaling,

lichenified papules and plaques– Management

• Avoid allergen• Tap water compresses or soaks, topical corticosteroids

• Milaria (Prickly Heat)– Etiology

• Continued exposure to heat and moisture causing retention of perspiration by sweat glands

– Signs and Symptoms• Itching and burning vesicles and pustules• Occurs most often on arms, trunks, and bending

areas of the body– Management

• Avoidance of overheating, frequent bathing with non-irritating soap, wearing loose-fitting clothing and use of antipruritic lotions

• Chilblains (pernio)– Etiology

• Caused by excessive exposure to cold– Signs and Symptoms

• Tissue does not freeze but reacts with edema, reddening and possibly blistering along with a sensation of burning and itching after exposure to cold

– Management• Exercise and gradual warming of the part• Massage and application of heat are contraindicated• Some systemic drugs can be used in severe cases

• Sunburns– Etiology

• Inflammatory response to injury caused by ultraviolet solar radiation

• Must be cautious of physical characteristics, chemicals, food and drugs that make individuals more susceptible

– Signs and Symptoms• Varies from erythema to severe blistering• May experience shock if severe enough• Can cause malfunctioning of organs w/in the skin• Will appear 2-8 hours following exposure, with

symptoms becoming most severe at 12 hours• S&S will dissipate w/in 72-96 hours

• Sunburns (continued)– Management

• Can be prevented through the use of sunscreen (sun protection factor or SPF)

– Filters ultraviolet light– Water/sweat resistant sunscreen is recommended

• Treat a burn according to the degree of inflammation

• Cool water, aloe based solutions• More severe burns may require bathing in a bath of

cornstarch or vinegar• Severe burns require physician assistance

• Psoriasis– Etiology

• Exact cause is unknown -- genetic factors may play a role in condition

• Infection, smoking, some drugs and possible hormonal factors may cause an outbreak

– Signs and Symptoms• Lesion begins as reddish papules that progress to

plaques• Lesions progress to yellowish white scaly condition

that tends to be located on the elbows, knees, trunk, genitalia, and umbilicus

• Psoriasis (continued)– Management

• Teaching patient self management• Glucocorticoids and kerolytic agents can be used in

conjunction with each other• Long term oral medications may be necessary• Counseling may be necessary for psychological

aspects of condition

Infestation and Bites• Scabies

– Etiology• Caused by mites which cause extreme nocturnal itching (tunnels

and lays eggs)– Signs and Symptoms

• Appear as dark lines between fingers and toes, body flexures, nipples and genitalia

• Excoriations, pustules and papules caused by itching tends to hide true cause

• Skin develops hypersensitivity to the mite– Management

• Permethrin 5% is treatment of choice• Washing of bedding and clothes is necessary• Topical corticosteroids may be necessary to treat itching

• Lice (Pediculosis) – Etiology

• Manifestation by the louse (louse of head, pubic region and body)

– Signs and Symptoms• Bites cause itching dermatitis through subsequent

scratching -- promotes pustule and excoriations to develop

– Management• Cure is rapid with use of any number of agents• Good hygiene is paramount• To prevent re-infestation all clothing and bedding

should be washed in hot soapy water or discarded

• Fleas– Etiology

• Small wingless insects that suck blood• Can transmit systemic diseases

– Signs and Symptoms• Great deal of discomfort can be felt if come into

contact with a high number of fleas• Concentrate bites on ankles and lower legs

– Management• Following a bite, itching must be prevented with

antipruritic lotion• Avoid scratching to prevent secondary infection• Insecticides can also be effective

• Ticks– Etiology

• Parasitic insects that have an affinity for blood• Carriers of a variety of microorganisms that can

transmit Rocky Mountain spotted fever and Lyme disease

– Signs and Symptoms• Headaches, fever, malaise, myalgia, and rash,

perechiae and prupura, enlarging annular red ring w/ or w/out central red papule

– Management• Remove tick (mineral oil or fingernail polish)

– Grasping head of tick is an acceptable method• Systemic treatment is necessary to prevent morbidity

and mortality associated with RMSF and Lyme disease

• Mosquitoes– Etiology

• Unless carrying a disease, mosquitoes produce bites that cause only mild discomfort

• Attracted to lights, dark clothing and warm moist skin– Signs and Symptoms

• Small reddish papule with associated itching– Management

• Topical medication• Use of repellents can also be used on the skin to prevent

contact with mosquitoes

• Stinging Insects– Etiology

• Bees, wasps, hornets, yellow jackets -- inflict venomous sting

• Hypersensitive individuals may experience an allergic reaction

– Signs and Symptoms• If an allergic reaction occurs an increase in heart

rate and breathing will occur, along with chest tightness, dizziness, sweating and even LOC

• Insect Stings (continued)– Management

• To prevent, avoid wearing scented lotions or shampoos, brightly colored clothes, jewelry, suede, or leather, and avoid going barefoot.

• If an athlete is susceptible to anaphylactic reactions instructions on use of an EpiPen are necessary

• If uncomplicated, the stinger should be removed with tweezers or a credit card and soothing medications should be applied

• Soap detergent will also lessen symptoms• In cases of anaphylactic reaction immediate physician

referral is necessary

Taking history

• The diagnosis of skin disease begins with taking a history.

• This is followed by careful physical examination.

• If at this stage a diagnosis has not been made, further examinations should be carried out.

• 3 History of presenting condition How long has the lesion(s) been present? This is the most important question in the history. Acute lesions presenting for less than two weeks need to be distinguished from those that are chronic.

• Do the lesions come and go? • Do they occur at the same sites or different sites?

This is important if a diagnosis of urticaria or herpes simplex is being considered.

• Was the lesion caused by trauma/insect bite? • Is there any associated discharge or odour? • Has the patient travelled abroad recently?

3 Relationship to physical agents A past history of living or working in a hot climate may be the clue you need to diagnose skin cancer. • Sun exposure is often indicated by a rash on the face or back of the hands.

The important question here is the time interval after sun exposure until the rash appears. In solar urticaria, the rash appears within five minutes of sun exposure and is gone within an hour; in polymorphic light eruption, the rash occurs several hours after sun exposure and lasts several days.

• Ask about irritants on the skin if the patient has hand eczema. Common irritants include detergents, oils and some solutions that are found in the workplace (hairdressers, dental workers).

• Are the hands in direct contact with irritants? • What makes the skin condition better? • What makes the skin condition worse? • What treatment has been used to date

(medical, herbal and over the counter (OTC))?

• 3 Pruritus (Itching) Pruritus (itchy skin) is the single most common symptom of many inflammatory skin conditions.

• Dry skin itself is itchy and requires management with emollient therapies. • While itching is distressing to the patient, it may not help you reach a

diagnosis. • Excoriation (scratch marks) on the skin provide evidence of pruritus. • Severe itch, especially at night, may be caused by scabies. • Management of pruritus is an essential component of overall

management of the skin condition

• 3 Past medical history Conditions which may be associated with skin disease include diabetes, cancer, renal/liver disease and immunodeficiency.

• Family history -• This will indicate that either the skin disease is

genetically determined (e.g., atopic eczema, psoriasis, ichthyosis) or contagious (e.g. scabies or impetigo).

• Social history/hobbies/occupation/recent travel to foreign country: For instance, does hand dermatitis get better at the weekend, or on holiday?

• Hobbies may indicate contact with irritant products or chemicals, etc. Travel to a warm climate may expose the person to tropical infection.

Examining the skin and describing lesions

• The entire skin surface, as well as hair, nails and mucosal surfaces, should be examined.

• In order to carry out the examination, you may require the patient to undress down to underwear.

• If the patient has a widespread rash, it may seem obvious to them that you have to examine their skin in its entirety.

• They may however question the need for a full skin examination if they present with an isolated lesion.

• There may be other lesions the patient has not seen, perhaps on the back or buttocks. It is important to explain this to the patient without alarming them.

• A gown or blanket should be available. The room should be warm with good lighting. An additional light source and magnifying lens are also useful.

• It is important to be aware of, and sensitive to, cultural and religious differences, and a chaperone may be required in some circumstances

Common presentations of skin lesions

• To make an accurate diagnosis, skin examination should follow a pattern. It is important to carry out the following.

Describing a lesion Note the distribution and colour of lesions. Are they: • localised (e.g. a tumour)? • widespread (e.g. a rash)? • if widespread, is it symmetrical and, if so, central or peripheral? • does it involve the flexures (e.g. atopic eczema)? • does it involve the extensor aspects (e.g. psoriasis)? • is it limited to sun-exposed sites? • is it linear? • is it regional (e.g. groin or axilla)? • does it follow a dermatomal (corresponding to root nerve distribution) pattern (e.g. shingles)?

Examine the morphology • Examine the morphology (form and structure) of individual lesions. A

magnifying lens is helpful. Consider: • size • shape (e.g. linear, grouped, annular, koebner phenomenom (an inflammatory skin response at the site of previous trauma)) • border change (e.g. pearly edge, rolled edge) • depth − are lesions dermal or epidermal? • is it macular (flat) or forming papules? • is it fluid filled – serous fluid or pus? • is it indurated (hardened) or forming plaques? • is it forming crusts, scabs, vesicles: if scaly, does surface flake off easily; if crusted, what is underneath?

Palpation

• Palpate to check consistency. This should be done by compressing the lesion between the finger and thumb (in widespread rashes, this may not be necessary) :

Investigations

• Swab for bacterial investigations – ensure swab tip is moistened, roll swab in a zig-zag motion rotating between fingers. • Swab for viral investigations – pierce vesicle and swab fluid inside. • Mycology for fungal or yeast infection investigations – skin scrapings, nail clippings, hair debris. • Common blood tests as shown

Key points•Examine the entire surface area including scalp, axillae, groin and finger/toe webs. • Good lighting and a hand lens are important. • Use a systematic approach to assessment: describe the lesion(s) and their distribution, examine morphology, palpate the lesion(s), note any change in colour. • Note changes or abnormalities in nails, hair and mucous membranes. • Carry out relevant investigations or refer to dermatology if more specialised investigations are required.