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02 June
2014

Assessment of the Skin and Lesions

Alfredo Guzman, MD
The adrenaline and stress of an adventure are better than a thousand peaceful days.
Paulo Coelho
SKIN LESIONS Paulo Coelho
COMPOSITION OF A USEFUL SKIN EXAMINATION
Morphology (shape of the lesion)
Configuration (arrangement of lesions)
Distribution (Which body site)
TECHNIQUES OF EXAMINATION
* additional notes from Bates Guide to Physical Examination
and History Taking
1. Ensure that the patient wears a gown and is draped
accordingly to facilitate close inspection of the following:
Hair
Anterior and posterior surfaces of the body
Palms and soles
Web spaces between the fingers and toes
2. Inspect the entire skin surface in good light, preferably
natural light or artificial light that resembles it
Artificial light often distorts colors and masks
jaundice.
3. Correlate your findings with observations of the mucuos
membranes, especially when assessing skin color, because
diseases may appear in both areas
SKIN
A. COLOR
1. Ask if patient observed a change in skin color.
Increased pigmentation (browness)
Loss of pigmentation
Redness
Pallow
Cyanosis
Yellowing of skin
2. Assess the red color of oxyhemoglobin and the pallor
in its absence where the horny layer of the epidermis
is thinnest and causes the least scatter.
Fingernails, lips, mucous membranes of mouth
and palpebral conjunctiva
In dark people inspecting palms and soles may
also be useful
CENTRAL CYANOSIS best defined in the lips,
oral mucosa and tongue
3. Look for the yellow color of jaundice in sclera.
May also be seen in palpebral conjunctiva, lips,
hard palate, undersurface of tongue, tympanic

MORPHOLOGICAL CLASSIFICATION OF LESIONS

Primary Skin Lesions unmodified lesions
Secondary Skin Lesions modified by scratching or infections
membrane, skin
To see jaundice in the lips, blanch out the red
color by pressure of glass slide.
Yellowness associated with high levels of
carotene (carotenemia), assess palms, soles,
and face.
B. MOISTURE Dryness, sweating, and oiliness
C. TEMPERATURE
1. Use back of fingers to make general assessment.
2. Note the temperature in any red areas.
D. TEXTURE roughness and smoothness
E. MOBILITY AND TURGOR
Lift the skin and note the following:
o Ease with which it lifts up Mobility
o Speed with which it returns into place Turgor
F. LESIONS
EVALUATING BEDBOUND PATIENTS
Assess patient by inspecting the skin that overlies the
scrotum, buttocks, greater trochanters, knees, and heels.
Pressure sores caused by sustained compression that
obliterates arteriolar and capillary blood flow to the skin.
HAIR
Inspect and palpate hair. Note its quantity, distribution, and
texture.
NAILS
Inspect and palpate the fingernails and toenails. Note the
color, shape, and any lesions.
Longitudinal bands of pigment normal in people with
dark skin

I. PRIMARY SKIN LESIONS

GENERAL
CHARACTERISTIC
FLAT

CLASSIFIED AS

MACULE

PATCH
RAISED (SOLID)

PAPULE

NODULE

TUMOR

PLAQUE

TRANSCRIBED BY: LUKE, LEIA, HAN, CHEWBACCA

DESCRIPTION
change in skin color
up to 1 cm
cannot be palpated

If macule is greater than 1 cm

solid raised lesion with distinct borders
less than 1 cm in diameter
may have a variety of shapes in profile (domed, flat-topped,
umbilicated)
may be associated with secondary features: crusts or
scales
a raised solid lesion more than 1 cm
it may be in the epidermis, dermis, or subcutaneous tissue

a solid mass of the skin or subcutaneous tissue

larger than a nodule
not necessarily a neoplasm
a solid, raised, flat-topped lesion greater than 1 cm in
diameter.
it is analogous to the geological formation, the plateau

EXAMPLE
freckles, neurofibromatosis with
caf au lait macules,
hypopigmented macules and
patch, vitiligo;
hemangioma
scabies, molluscum
contagiosum, Id reaction to
fungal infection,
papulosquamous lesions (buni)

basal cell cancer, nodule in the

axilla (lymph node in cat scratch
fever)
AV malformation, xanthomas

tuberous sclerosis, psoriasis

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Skin and Lesions

RAISED (FILLED)

I. PRIMARY SKIN LESIONS

raised lesions less than 1 cm in diameter that are filled
with clear fluid
circumscribed fluid-filled lesions that are greater than 1
cm in diameter

VESICLES
BULLAE

circumscribed elevated lesions that contain pus

most commonly infected (as in folliculitis) but may be sterile
(as in pustular psoriasis)
area of edema in the upper epidermis
linear lesions produced by infestation of the skin and
formation of tunnels

PUSTULES
WHEAL
OTHERS
BURROWS

permanent dilatation of superficial blood vessels in the

skin
may occur as isolated phenomena or as part of a
generalized disorder, such as ataxia telangiectasia

TELANGIECTASIA

hand, foot, and mouth disease

Stevens-Johnsons Syndrome,
Contact dermatitis, severe
allergy
group A beta-hemolytic
streptococcus infection
urticaria (hives), insect bites
with infestation by the scabitic
mite (galis aso) or by cutaneous
larva migrans
spider or starburst
telangiectasia

II. SECONDARY SKIN LESIONS

CLASSIFICATION
1. SCALE

2. CRUST

3. ATROPHY

4. LICHENIFICATION

DESCRIPTION
consists of flakes or plates that represent compacted
desquamated layers of stratum corneum.
desquamation occurs when there are peeling sheets of scale
following acute injury to the skin.
Exfoliation of epidermis
result of the drying of plasma or exudate on the skin.
Note: Please remember that crusting is different from scaling.
The two terms refer to different phenomena and are not
interchangeable. One can usually be distinguished from the
other by appearance alone.
thinning or absence of the epidermis or subcutaneous fat
(-) hair, sweat and oil due to lack of sebaceous and sweat glands
refers to a thickening of the epidermis seen with exaggeration
of normal skin lines.
It is usually due to chronic rubbing or scratching of an area.
are slightly depressed areas of skin in which part or all of the
epidermis has been lost

5. EROSION

6. EXCORIATION

are traumatized or abraded skin caused by scratching or

rubbing.
linear cleavage of skin which extends into the dermis

7. FISSURE
8. ULCERATIONS

9. SCAR

10. ESCHAR

11. KELOIDS
12. PETECHIAE, PURPURA,
ECCHYMOSES (Bruise)

occur when there is necrosis of the epidermis and dermis and

sometimes of the underlying subcutaneous tissue.
Permanent fibrotic changes that occur on the skin following
damage to the dermis.
Shiny, dry , thin
a hard plaque covering an ulcer implying extensive tissue
necrosis, infarcts, deep burns, or gangrene
look like very big ulcers
an exaggerated connective tissue response of injured skin that
extend beyond the edges of the original wound.
three terms that refer
to bleeding that
occurs in the skin
easy bruising in
unlikely areas

PETECHIAE - smaller lesions

> DO NOT BLANCH
PURPURA & ECCHYMOSES- larger
lesions
> DO NOT BLANCH
HOW TO DIFFERENTIATE A
PALPABLE PURPURA FROM A
RASH:
press on the lesions carefully with a
glass slide; purpura do not blanch
when pressed

DISTRIBUTION

TRANSCRIBED BY: LUKE, LEIA, HAN, CHEWBACCA

III. DISTRIBUTION OF SKIN LESIONS

DESCRIPTION

EXAMPLE
seborrheic dermatitis, tinea capitis
(poknat), Kawasaki disease
cradle cap among infants may
signify that infant is prone to allergy
and skin disease when he/she
grows up
peri-oral lesions in impetigo (honey
colored adherent crust)

linear areas of atrophy (striae)

secondary to chronic systemic
steroid administration; result of
advanced graft vs. host disease.
pruritic scabies usually in the web
spaces between fingers
tx: use anti-itch creams
consequences of a self-inflicted
chemical burn, associated with
Stevens-Johnson syndrome
in SJS all epidermal cells are
affected: GI and visceral cells, so px
is given antiulcer medications
swimmers itch
a fissure at the angle of lips as a
consequence of Kawasaki disease
extensive ulceration of her lips after
having chewed on a live electrical
wire
may have secondary pigment
characteristics
meningococcemia
keloid at the site of an old lymph
node biopsy site
petechiae from thrombocytopenia
secondary to chemotherapy,
purpura associated with the disease
Henoch-Schnlein Purpura, suction
purpura caused by the medical
practice of cupping which has its
origins in antiquity, purpura and
ecchymosis on the skin as
presenting symptoms of acute
myelogenous leukemia

EXAMPLE

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Skin and Lesions

1. PHOTODISTRIBUTED
2. INTERTRIGINOUS

on areas exposed to the sun

on areas where skin rub each other; often wet and irritated
along creases and fold
along the path of lymph channels of leg or arm

3. LYMPHANGITIC
4. DERMATOMAL

5. PALMS AND SOLES

area of skin following sensory innervations of a particular nerve

root
does not cross midline of body
Along palms and soles. You dont say.
V. PATTERNS OF SKIN LESIONS
DESCRIPTION

PATTERNS
seen in a ring shape
1. ANNULAR

2. DISCRETE

tend to remain separate

has little specific diagnostic significance
are grouped together

face, neck, decolette, dorsal part of feet

axillary area
inguinal area
inframammary fold
leg and arm lymph path
fungal infection: sporotrichosos
T4 along nipple line
C5- along shoulder
Herpes zoster

EXAMPLE
Tinea corporis
erythema migrans (the lesion associated with
lyme diseas
granuloma annulare
vesicles of varicella in a discrete pattern

inflamed with a tendency toward clustering, oozing, or crusting

commonly seen in herpes simplex or with insect

bites
macular lesions of Kawasaki disease
Dengue Hemorrhagic Fever
The lesions of varicella zoster (also known as
shingles); other lesions may assume the same
pattern
atopic dermatitis

lesions that specifically involve the hair follicle

keratosis pilaris

look as though someone took a dropper and dropped this lesion

on the skin
look like the bulls eye in dartboards

Guttate lesions are characteristic of one form of

psoriasis, though that is not the only example
erythema multiforme
Kawasaki disease
lichen planus
warts
molluscum contagious
psoriasis
lichen nitidus
systemic form of juvenile rheumatoid arthritis

3. CLUSTERED
tend to run together
4. CONFLUENT
follow a dermatome
5. DERMATOSOMAL
/ZOSTERIFORM
6. ECZEMATOID
7. FOLLICULAR
8. GUTTATE
9. IRIS OR TARGET
LESIONS
10. KOEBNER
PHENOMENON

11. LINEAR

12. MULTIFORM
13. RETICULAR

14. SERPIGINOUS

also called the isomorphic response

the appearance of lesions along a site of injury
o Auspitz sign
tiny bleeding points (due to suprapapillary thinning) when
you remove a scale from psoriasis lesion
o Dariers sign
when you stroke lesion of urticaria
pigmentosa (form of cutaneous mastocytosis)
erythema & edema (due to mast cell degranulation with
histamine release)
o Nikolsky sign
when you rub normal skin beside blister induction of
new blister
seen in pemphigus vulgaris and toxic epidermal
necrolysis(ten)
o Dermatographism
when you stroke the normal skin edema and erythema
(you can write on skin!)
seen in physical urticaria
occur in a line or band-like configuration.
term may apply to a wide variety of disorders
one should be certain that the lesions are not following a
dermatome
lesions of a variety of shapes
net-like lesions
can be seen in a variety of circumstances

17. STRAWBERRY TONGUE

linear streaking associated with the lesion of

lichen striatus, poison ivy dermatitis
lymphangitis with linear streaking following
the line of the lymph system
erythema multiforme
very commonly in newborns (or even grown
children and adults) as cutis marmorata, or
with livedo reticularis. The former fades as
the skin is warmed the latter becomes more
florid
urticaria following a serpiginous route
alopecia universalis (patient with complete
absence of hair on his body, including the
absence of eyelashes and eyebrows)

wander as though following the track of a snake

refers to a widespread disorder that affects the entire skin

have the pattern of scarlet fever

the patient with a scarlatiniform rash has innumerable small red
papules that are widely and diffusely distributed
note that the term scarlatiniform does not mean that the patient
has scarlet fever, although by definition all patients with scarlet
fever have a scarlatiniform rash.
distinctive appearance in the tongue among patients with scarlet
fever, Kawasaki disease or other conditions
because of its resemblance to the well-known berry, the
appearance is called "strawberry tongue."

Kawasaki disease, viral infections, or drug

reactions

15. UNIVERSALIS

16. SCARLATINIFORM

TRANSCRIBED BY: LUKE, LEIA, HAN, CHEWBACCA

scarlet fever
Kawasaki disease

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Skin and Lesions

18. MORBILLIFORM

19. SATELLITE

20. PATTERNS OF
INTENTIONAL/UNINTENTIO
NAL INJURY

since this eruption is on a mucus membrane, it is called an

enanthem
a rash that looks like measles
patients with measles will have the rash but patients with
Kawasaki disease, drug reactions, or other conditions may also
have a morbilliform rash.
consists of macular lesions that are red and are usually 2-10
mm in diameter but may be confluent in places
a portion of the rash of cutaneous candidiasis in which a beefy
red plaque may be found surrounded by numerous, smaller
red macules located adjacent to the body of the main lesions
in cases of child abuse or other intentional injury (bite marks, slap
marks, strap marks, burns, etc.) or in cases of unintentional injury
abrasions are traumatically caused erosions

measles
drug reaction to Dilantin

candidal diaper dermatitis

rollerblading mishap
cigarette burn
linear ecchymosis from car crash
Battle sign: sign of basilar skull fracture;
bruising behind the ear

VI. COLOURS IN DERMATOLOGY

RED

Vascular lesions e.g. port wine stain; inflammatory disorders (psoriasis)

BLUE

Blue nevus; Mongolian spot

YELLOW

Xanthoma: deposition of yellow cholesterol rich material on tendons/ other body parts

WHITE

Vitiligo: Michael Jackson

BLACK

Melanocytic nevus ; melanoma

PURPLE/ VIOLACEOUS

Lichen planus

Configuration
Flat-topped

VII. CONFIGURATION
Disease
Lichen planus

Dome-shaped

Lymphomatoid
papulosis

Slightly elevated

Panniculus

Acuminate

Acute spongiotic
dermatitis

Papillated

Intradermal nevus

Digitated

Wart

Umbilicated

Molluscum
contagiosum

TRANSCRIBED BY: LUKE, LEIA, HAN, CHEWBACCA

Figure

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