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Chapter 15: Skin

Lori D. Prok; Carla X. Torres-Zegarra

GENERAL PRINCIPLES

DIAGNOSIS OF SKIN DISORDERS

Examination of the skin requires that the entire surface of the body be palpated and inspected in good light. The onset and duration of each symptom should be recorded, together with a description of the primary lesion and any secondary changes, using the terminology in Table 15–1. In practice, characteristics of skin lesions are described in an order opposite to that shown in the table. Begin with distribution, then configuration, color, secondary changes, and primary changes. For example, guttate psoriasis could be described as “generalized, discrete, red, or scaly papules.”

Table 15–1.Examination of the skin.
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Table 15–1. Examination of the skin.
Clinical Appearance Description and Examples
Primary lesions (first to appear)
Macule Any flat circumscribed color change in the skin < 1 cm. Examples: white (vitiligo), brown (junctional nevus), purple (petechia).
Patch Any flat circumscribed color change in the skin > 1 cm. Examples: white (nevus depigmentosa), brown (café au lait macule), purple (purpura).
Papule A solid, elevated area < 1 cm in diameter whose top may be pointed, rounded, or flat. Examples: acne, warts, small lesions of psoriasis.
Plaque A solid, circumscribed area > 1 cm in diameter, usually flat-topped. Example: psoriasis.
Vesicle A circumscribed, elevated lesion < 1 cm in diameter and containing clear serous fluid. Example: blisters of herpes simplex.
Bulla A circumscribed, elevated lesion > 1 cm in diameter and containing clear serous fluid. Example: bullous impetigo.
Pustule A vesicle containing a purulent exudate. Examples: acne, folliculitis.
Nodule A deep-seated mass with indistinct borders that elevates the overlying epidermis. Examples: tumors, granuloma annulare. If it moves with the skin on palpation, it is intradermal; if the skin moves over the nodule, it is subcutaneous.
Wheal A circumscribed, flat-topped, firm elevation of skin resulting from tense edema of the papillary dermis. Example: urticaria.
Secondary changes
Scales Dry, thin plates of keratinized epidermal cells (stratum corneum). Examples: psoriasis, ichthyosis.
Lichenification Induration of skin with exaggerated skin lines and a shiny surface resulting from chronic rubbing of the skin. Example: chronic atopic dermatitis.
Erosion and oozing A moist, circumscribed, slightly depressed area representing a blister base with the roof of the blister removed. Examples: burns, impetigo. Most oral blisters present as erosions.
Crusts Dried exudate of plasma on the surface of the skin following disruption of the stratum corneum. Examples: impetigo, contact dermatitis.
Fissures A linear split in the skin extending through the epidermis into the dermis. Example: angular cheilitis.
Scars A flat, raised, or depressed area of fibrotic replacement of dermis or subcutaneous tissue. Examples: acne scar, burn scar.
Atrophy Depression of the skin surface caused by thinning of one or more layers of skin. Example: lichen sclerosus.
Color
  The lesion should be described as white, red, yellow, brown, tan, or blue. Particular attention should be given to the blanching of red lesions. Failure to blanch suggests ...

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