C
linicians are sometimessurprised when they re-fer an animal with a der-matologic problem to a specialistwho rapidly compiles a list of dif-ferential diagnoses and pinpointsspecific tests to be performed.There is nothing magical aboutthe dermatologist’s action! Al-though dermatologists routinelysee various cutaneous lesions, itis their ability to properly identifythese lesions that provides thecritical information necessary tocompile a list of diagnostic differ-entials and select appropriatetesting.Key to making a diagnosisand treating a previously unseendermatologic problem is keep-ing an open mind to the possi-bility of a novel diagnosis andstarting with the usual historytaking. After a very thoroughhistory, the basic morphologyof cutaneous lesions must bereviewed. Then, the predomi-nant pattern of lesions shouldbe determined and the same al-gorithmic approach used forany other problem followed.To make a correct dermato-logic diagnosis, clinicians mustfirst be able to recognize prima-ry and secondary lesions andbe able to associate them with apredominant morphologic pat-tern. This column focuses onthe evidence that clinicians can
see
during a clinical examina-tion; this evidence is coupledwith the patient history to nar-row the diagnostic possibilities.Although seemingly easy,correctly describing a skin con-dition can be quite difficult. Todo pattern diagnosis effectively,descriptions must be preciseand accurate. Differentiating ascale from crust or a papulefrom a plaque, for example, iscritical. Without a correct de-scription of the morphologicpattern, accurate diagnosis isusually impossible. Table Oneprovides an easy-to-use list oflesions, their descriptions, andthe morphologic pattern associ-ated with each. In summary,approaching each case in threedistinct steps will allow the clin-ician to make a correct diagno-sis in most cases (see the box).
Determine Pattern
Using your knowledge of pri-mary and secondary lesions,carefully evaluate the animal todetermine the predominantpat-tern. This is done by asking a se-ries of questions in a specific or-der (see the algorithm). Alwaysselect the predominant pattern. Adog with profound scaling andthree pustules does not have avesiculopustular disorder; it has
The Compendium
September 1996Small Animal
tables provided here (Tables Twothrough Nine). Making such a listnot only increases your aware-ness of possible dermatologicconditions but provides an ex-tremely helpful reference thatcan accompany samples submit-ted for diagnostic testing (espe-cially biopsies for histopathologicassessment).
Perform DiagnosticTesting
With a pattern diagnosis anddifferential diagnostic list, thepossible diagnoses can be nar-rowed. With experience, it is
The Pattern Approach toDermatologic Diagnosis
PERSPECTIVES IN VETERINARY MEDICINE
Lowell Ackerman, DVM, PhDDiplomate, ACVDDermvet Inc.Scottsdale, Arizona
an exfoliative dermatosis. A catwith a large, hairless mass on itsback has a papulonodular der-matosis, not alopecia. There areeight major categories of pre-dominant patterns.
Formulate DifferentialDiagnostic List
Once you have determined thefit between your case and one ofthe eight major categories, youcan create a comprehensive dif-ferential diagnostic list from thepossible to prioritize the mostlikely diagnoses and performtests accordingly. At first, how-ever, information in Table Tencan be used to create a mini-mum data base, which will revealthe most common condition as-sociated with a particular presen-tation. If the minimum data basedoes not suggest a diagnosis,proceed to the
“
next step
”
col-umn in Table Ten. By followingthis approach, a diagnosis canbe made in most cases.
s
Most dermatologic problems have a characteris-tic clinical presentation.
s
A differential diagnostic list can often be madeby assigning clinical cases into one of eightmajor categories of predominant lesion patterns.
s
Deciding which diagnostic tests to performbecomes more routine if the lesions have beengrouped into one of the eight major categories.
K E Y P O I N T S
V
How To Make a CorrectDermatologic Diagnosis
Step 1
Determine pattern.
Step 2
Formulate differential diagnostic list.
Step 3
Perform diagnostic testing.
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