INVESTIGATIONS AND SPECIALISED

EXAMINATION

Diagnosis in dermatology relies almost entirely on clinical skills , and

the role of investigations is limited.
Dermatoscopy
• Also known as dermoscopy or
epiluminescence microscopy,
• this can be performed with a magnifying
lens and oil applied to the skin, which
reduces specular reflection and allows the
observer to ‘see through’ the epidermis
better.
• This is important in the assessment of
pigmented lesions such as melanoma and
naevi.
• Similar effects can be achieved by the use
of illumination with polarised light and a
lens, allowing non-touch imaging of the
skin.
Diascopy
• Distinguishing between blood and
melanin, the main two pigments (or
chromophores) in the skin, can be difficult.
• Pressing on the lesion with the corner of a
glass slide will remove blood from vascular
lesions, causing them to blanch.
• However, failure to remove blood does
not reliably exclude a vascular lesion, as
the vascular anatomy may sometimes be
particularly convoluted.
• Pressing with a glass slide on some
granulomatous lesions (such as cutaneous
tuberculosis) gives an appear ance known
as ‘apple jelly’ nodules.
 Wood’s light
• Exposure of skin to long wavelength
ultraviolet radiation (UVA) with a Wood’s
light causes collagen in the dermis to
fluoresce.
• In patients with hypopigmentation, Wood’s
light accentuates the difference in colour
between the pigmented and non-pigmented
areas because the pigment in the epidermis
blocks the UVA photons before they can
elicit fluorescence in the dermis.
• This can be helpful in mapping out the areas
of depigmentation
• . Under Wood’s light, green fluorescence is
seen in scalp ringworm due to Microsporum
canis ,
Incisional biopsy and histopathology
• The purpose of an incisional biopsy is to obtain a sample of tissue for
his topathological examination rather than definitive treat ment of a
lesion, for which excisional biopsy is required.
• Skin biopsies are usually taken under local anaesthetic.
• It is best to select an early or typical lesion on a non exposed site that
is not affected by secondary excoriation
Immunofluorescence
• A portion of the biopsy can be frozen in liquid nitrogen for direct
immunofluorescence (IF).
• This allows visuali sation of antigens that are present in the skin using
spe cific fluorescein-labelled antibodies.
• Similarly, indirect immunofluorescence can identify circulating
antibodies in the serum by adding the serum to a section of normal
skin or other substrate.
• Immunofluorescence plays a major role in the diagnosis of the
autoimmune bullous disorders
Microbiology
• 1. Mycology
• Cutaneous scale, nail clippings and plucked hairs can be examined by
light microscopy when mounted in 20% potassium hydroxide.
• The keratin is dissolved, allowing fungal hyphae to be identified.
• If the potas sium hydroxide solution contains Indian ink, the typi cal
‘spaghetti and meatballs’ hyphae and spores of the yeast
Pityrosporum orbiculare can be readily identified in pityriasis
versicolor.
• 2. Bacteriology
• Bacterial swabs may identify a causative infective agent.
• However, organisms identified from the surface of the skin may not
be implicated in the underlying disease, but reflect colonisation of
skin damaged by a primary disease.
• Conversely, in diseases such as cellulitis, swabs often do not reveal the
causative agent.
• If pustules are present, one should be punctured with a fine sterile
nee dle and the pus exuded gently on to a swab
• 3. Virology
• A number of techniques, including immunofluores cence and
polymerase chain reaction (PCR), are avail able to diagnose herpes
simplex or herpes zoster viruses
Prick tests
• Prick tests are a way of detecting cutaneous type I (imme diate)
hypersensitivity to various antigens such as pollen, house dust mite or
dander.
• The skin is pricked with commercially available stylets through a
dilution of the appropriate antigen solution.
• Alternatively, specific IgE levels to antigens can be measured in serum.
 Patch tests
• Patch tests detect type IV (delayed or cell-mediated) hypersensitivity.
• A ‘battery’ of around 20 common antigens, including common sensitisers
such as nickel, rubber and fragrance mix, are applied to the skin of the
back under aluminium discs for 48 hours.
• The sites are examined for a positive reaction 48 hours later.
• An eczematous reaction in the absence of an irritant reaction suggests a
type IV hyper sensitivity to that particular allergen.
• The relevant antigens for a particular clinical case may not be in the
standard battery of tests so expert advice may be needed.
• A negative patch test does not exclude a pathogenic role for a particular
antigen, nor does a response to an antigen mean that it is necessarily
causing the clinical disease.
WHAT TO EXPECT

• During the initial visit, which lasts approximately 30 minutes, the nurse will
apply one or more small aluminum disks to an area on pts upper back
(used as the test site because the strongest responses are seen in this area).
• These disks, or patch test kits, contain small amounts of each suspected
chemical or allergen; the substances to be tested are determined by the
dermatologist or other health care provider.
• A visible reaction in the skin in contact with a disk indicates allergy to the
substance contained in that disk. This redness or rash may itch and persist
for several days to several wee
• Pt is advised to return 48 hours later. At this time, the nurse will remove the
patches, mark on skin, and do the first reading;
• A final reading will be done on next visit, which will take place 96 hours
after the disks have been removed.
DO'S AND DON'TS
• DO wear loose or high-necked clothing throughout the day. Hint: Wear a T-shirt to bed
to avoid catching the edges of the tape on the bed sheets.
• DO apply tape to the patch edges if they become loose.
• DO contact your health care provider immediately if a patch test area burns severely
or if you are unable to carry out normal daily activities. Note: Some itching will occur
if you are having a positive reaction; you do not need to call your dermatologist.
• DO NOT wet the patches during the testing period—for example, do not take
showers. Sponge baths are allowed as long as care is taken to keep the patches
completely dry.
• DO NOT engage in strenuous activities. Exercise may result in excess sweating, thereby
causing the tape to loosen.
• DO NOT expose your back to the sun for 2 weeks before patch testing.
• DO NOT discontinue antihistamine therapy (these agents do not affect test results).
• DO NOT use nonmedicated creams and lotions on your back for at least 24 hours
before testing (lotions and creams prevent patches from sticking).
 Phototesting
• Diagnostic phototesting is an essential
component of the investigation of presumed
photosensitive drug reactions and idiopathic
photodermatoses such as solar urticaria.
• It involves exposing skin (often on the back)
to a graded series of doses of ultraviolet
radiation (UVR) of known wavelength, either
on one occasion or repeatedly.
• In many photodermatoses, erythema will
occur at a lower dose of UVR than in the
normal population (e.g. drug-induced
photosensitivity), or the time course of
erythema may be prolonged (as in
xeroderma pigmentosum)