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How to Perform a Total Body Skin ExamMedical Student Core Curriculum in Dermatology

Last updated August, 201111Module GoalThe purpose of this module is:To help medical students develop a systematic approach to the skin examTo highlight the importance of examining the entire cutaneous surface

22Learning ObjectivesBy completing this module, the learner will be able to:Discuss the key questions that make up a dermatologic historyExplain the indications for a total body skin examRecognize the need for patient comfort and modesty during this examinationList the tools that can improve the quality of your skin examinationDevelop a systematic approach to the total body skin exam

33The Medical HistoryA dermatologic history is similar to that in other fields of medicine and includes:Chief complaintHistory of present illness (HPI)Past medical history (PMH)MedicationsAllergiesFamily historyHealth-related behaviorsSocial historyReview of systems44Key questions for a rashHPI:When did it start?Does it itch, burn, or hurt?Is this the first episode?Where on the body did it start?How has it spread (pattern of spread)?How have individual lesions changed (evolution)?Provoking/exacerbating factors?Previous treatments and response?

55Key questions for a rashROSAny associated symptoms?Past medical historyAsk about the atopic triad (asthma, allergies, atopic dermatitis)MedicationsTravel historyEnvironmental exposures

May also yield important information

66Key questions for a growthHow long has the lesion been present?Has it changed and, if so, how?Change in size?Shape?Color?Any itch?Bleeding?

77Key questions for a growthFurther questions that may be pertinent:PMH: Any history of skin cancer? What type? When?If melanoma, do you remember the tumor depth or mode of treatment?Family history: Any family members with skin cancer?Have any family members had melanoma?

88The Total Body Skin Exam (TBSE) includes inspection of the entire skin surface, including:the scalp, hair, and nailsthe mucous membranes of the mouth, eyes, anus, and genitals

The Skin Exam99Do not forget the so-called hidden areas places on the skin where lesions may be easily missedConchal bowl (concavity adjacent to the external auditory meatus), auditory canal, postauricular creases Medial canthi (angular junction of the eyelids), alar (nasal) groovesIntergluteal cleft and perianal skinInterdigital spaces

TBSE1010To identify potentially harmful lesions, of which the patient is unaware, including:skin cancers, such as basal and squamous cell carcinoma, and melanomapre-malignant lesions (actinic keratoses)To reveal hidden clues to diagnosise.g. psoriatic plaques on the buttocks or gluteal cleftTo inform your counseling to the patient on sun protective measurese.g. lentigines are a sign of sun damage and suggest the need for improved sun protectionReasons for performing a TBSE1111Personal history of skin cancerIncreased risk for melanomaTwo first-degree relatives with melanomaOver 100 nevi (moles)Patient with concerning or changing growthNew rash on bodyNew patient with undiagnosed skin conditionFollow-up patients with extensive skin conditions such as psoriasisIndications for a TBSE1212Essential elements for the skin examAdequate lightingUndressed patient, in a gownPreferably without makeup, watches, jewelryPrivacyRulerMagnifying glassAn open mind about what you are seeing1313The skin exam should be performed with adequate lightingnatural sunlight is bestif windows are in the exam room, open the blindsthe best artificial source is high-intensity incandescent lightIf lighting is too low, turn on as many lights as possible and position the patient directly under available lights

Getting started: Lighting1414Getting started: Undressed patientYou cannot diagnose what you cannot seeBefore starting the skin exam, ask the patient to undress to their bra and underwear and put on a gown with the opening to the backPut down a chux or exam table paper so their bare feet dont touch the floorTell the patient you will step out, and ask if they would like a chaperone during the examIf you expect to examine the breasts or genitalia of an opposite-gender patient, bring a chaperone regardlessDraw the curtain and step out of the room1515Getting started: Patient modestyUndressed patients feel very vulnerableAvoid keeping them waiting too long while undressedOffer a second gown or blanket if it is coldBefore untying a gown or moving it, ask permissionAsk the patient to expose the area being examined, and cover the area after it has been examined Say out loud what part of the body you want to examine nexte.g., Okay, now lets look at your chest and abdomen The patient will usually move the gown accordingly16Tools we use: RulerAccurately records the size of a lesion on successive examinationsMeasure in the longest axis first, then in the perpendicular axise.g., this papule is 6x4 mm

1717Tools we use: A penlight is used for side lightingDetects atrophy and fine wrinklingDistinguishes Flat from raised lesionsWhether lesions are solid or fluid-filledAlso helps look inside the mouth

1818Tools we use: Magnification

Inexpensive magnifying glasses may help detect fine detailsAvoid LED lights, which cast a blue hueDermatoscopes help evaluate patterns in pigmented lesionsRequires additional training to become proficient19Getting started: Sanitize your handsThe skin exam is tactile as well as visualYou must palpate lesions to tell if they are raised, flat, or atrophicMany dermatologists prefer to use gloves for moist areas (groin, axilla) or oozing, crusted lesionsKeep hands clean and nails trimmedRemember to sanitize your hands before and after every skin exam2020The TBSE must be complete and systematicWe will first discuss a method for the complete skin exam (TBSE) when the patient has a primary skin complaintThen we will discuss incorporating the skin exam into a complete physical examPerforming the Skin Exam2121Sequence of the Skin ExamThe following sequence may be used to perform the TBSE22

Initial PositionPatient seated with legs draped over side of exam table23FaceMedial canthiAlar creasesConchal bowlConjunctivaeLipsOral mucosaEarsScalpUse fingers or a Q-tip to part the hairNeck

Start with Head and Neck2424Back of scalpPostauricular foldsBack of neck

Back of Head and Neck2525Arms: fingernails, palms, and underarms

2626Your choice: sitting/standing, or lying downFrom this point on, some physicians prefer to continue the exam in a sitting position, then have the patient stand to see their legs and buttocksOthers prefer to have the patient lie down for the remainder of the exam2727Chest Exam

Can be examined seated, lying, or standingFor female patients, ask permission to examine the skin of the breasts

2828Abdomen Place a drape or sheet over the groin when examining the abdomenGenital areaAsk permission to examine the genital area Legs

Abdomen, Genital area, Legs2929Examine dorsal and plantar skin, in between the toes, and the toenails

Dont Forget the Feet3030Buttocks, intergluteal area, including the perianal area (ask permission)Legs, including heels

Buttocks, Legs, Feet3131The Integrated Skin ExamThe above approach to the TBSE is often performed in the dermatology clinic, however, a full skin exam can and should be done in other clinical settings A head to toe approach of the skin exam easily incorporates into the full physical exam

3232The Integrated Skin ExamPay attention to what is present on the skinStart each part with inspectionHEENT: look at scalp, forehead, eyelids, outer ear, postauricular sulcus, inside mouth, lipsCardiac: look at entire skin of the chest before listening to the heartPulmonary: be sure to look at the back before listening to the posterior lung fields3333The Integrated Skin ExamAbdomen: before listening for bowel sounds, look at the skinPelvic/Genitourinary exam: begin with inspection of the relevant regional skinExtremities: before checking pulses, reflexes, muscle strength and sensation, look at the skin of each extremityLook for nail changes in addition to capillary refillLook at feet (no socks) before checking pedal pulses and edema34Practice, Practice, PracticeHospitalized patients present an excellent opportunity to perform TBSEsYou may help make a critical or life-saving diagnosisPerform integrated skin exams on patients in different practice settings and patient populationsPerform supervised TBSEs while in training; senior physicians may provide key insight to help you improveLook for common growths on all your patientsIf you dont know what something is, ask a colleague or attending physician or consult a dermatology text35Special TipsAvoid pointing at lesions on the face with sharp objects like pens. This is particularly a pitfall when presenting skin findings to a supervisor. Use anatomic terms instead.Do not underexamine patients with limited mobility. Ask for assistance to help the patient change positions.When practical, look under dressings. Erythema can be hard to detect in skin of color. Look carefully and ask the patient if he or she thinks the area is pinker than normal.

36Special TipsWhile ultimately you must respect patients wishes about modesty, do not relent too easily when patients initially request only a focal exam of a problem and you feel other areas may be informative.Even a focal exam should include areas contralateral to the affected part to look for symmetric or asymmetric processes.Consider carefully whether TBSE should be done with or without other family members in the room.

37Skin Exam VideosClick here to view a video on the TBSEClick here to view a video on the Dermatologic Examination3838Take Home PointsThe dermatologic history for rashes and growths encompasses focused and relevant questionsThe TBSE should be complete and systematicPractice repeating the skin exam in the same order every time to avoid forgetting important elementsDo not forget the so-called hidden areas places on the skin where lesions may be easily missedRemember to consider patient comfort and modestyThe skin exam should always be incorporated into the full physical exam 3939AcknowledgementsThis module was developed by the American Academy of Dermatology Medical Student Core Curriculum Workgroup from 2008-2012.Primary authors: Susan Burgin, MD, FAAD; Sarah D. Cipriano, MD, MPH; Patrick McCleskey, MD, FAAD.Peer reviewers: Timothy G. Berger, MD, FAAD; Ron Birnbaum, MD.Revisions and editing: Sarah D. Cipriano, MD, MPH; Meghan Mullen Dickman.Last revised August 2011.4040ReferencesBerger T, Hong J, Saeed S, Colaco S, Tsang M, Kasper R. The Web-Based Illustrated Clinical Dermatology Glossary. MedEdPORTAL; 2007. Available from: www.mededportal.org/publication/462.Garg A, Levin NA, Bernhard JD, :Structure of Skin Lesions and Fundamentals of Clinical Diagnosis in: Wolff K, Goldsmith LA, Katz SI, Gilchrest B, Paller AS, Leffell DJ: Fitzpatrick's Dermatology in General Medicine, 7e: http://www.accessmedicine.com/content.aspx?aID=2965385.LearnDerm Tutorial, Lesion 1: How to Perform a Skin Exam. http://www.logicalimages.com/educationalTools/learnDerm/lesson1.htm.4141