Pre-placement

Question 1

What is important when examining the skin?

Answer 1

• Exposure: when examining the skin you need to look at the whole skin, it is advisable to ask the patient to change into a gown then expose as necessary
• Lighting + magnification: a thorough examination needs good lighting and magnification. As much light should be allowed into the room as possible. Large mobile lenses are usually available, otherwise use a magnifying glass.

Question 2

What do you wamt to ask in the PC and PMH for skin problems?

Answer 2

• Rashes PC: one site, many sites? e.g. site, spread, duration, associated symptoms, risk factors
• Lesions PC: single or many? Changing colour, size, shape and associated symptoms
• PMH: history of atopy in eczema, previous skin cancer, medical illnesses that are relevant to diagnosis or management

Question 3

What do you want to know in the drug history for skin problems?

Answer 3

• Drugs that cause the problem: acne + steroids, immunosuppression and skin cancer
• Drugs/creams
• What is the current treatment?
• Does it work?
• How long have they used it for?
• How much have they used?

Question 4

What is important to know in the SH for skin problems?

Answer 4

• Rashes: occupation, hobbies - contact dermatitis e.g. detergents, psychological impact of skin condition of QoL
• Lesions: hobbies - increased skin exposure (golf, fishing), sunburn, sunbeds, skin type

Question 5

What do you want to know in the FH of skin problems?

Answer 5

• Rashes: psoriasis, eczema, atopy

- Lesions: skin cancer e.g. melanoma

Question 6

What is involved in the examination of the skin?

Answer 6

• Look: observe the general distribution (central, peripheral, flexural, extensor) + site of lesions. Are they grouped together or annular as in tinea corporis (ringworm). What is the colour, shape and size of lesions?
• Palpate: temperature, surface texture, depth, blanching or not
• Examine hidden sites: nails (psoriatic changes), finger and toe webs (fungal infections, melanomas), scalp (hair can hide many things e.g. plaques + scale), the mouth (e.g. severe drug eruptions) + in flexures i.e. axilla, sub mammary + genital area, umbilicus
• Relevant general examination: e.g. lymph nodes, if lymphoma suspected, palpation of pulses in the case of a venous ulcer, joint examination in psoriasis
• Work down body - start at face/scalp, chest etc, at end patient to stand to look at back/back of legs

Question 7

What are primary skin lesions?

Answer 7

• Originate from previously normal skin, directly associated with a disease process
• Macule: change in skin colour, hyper- + hypopigmentation
• Patch: macule >1cm at its widest aspect
• Papule: solid raised lesion that has distinct borders + is <1cm in diameter
• Plaque: solid raised flat-topped lesion >1cm
• Nodule: solid raised non-flat topped lesion >1cm
• Wheal: papule or plaque from trauma/skin allergy - evansecent, goes down in ~24hrs
• Vesicle: raised lesion up to 1cm diameter, filled with clear fluid
• Bulla: raised lesion >1cm in diameter, filled with clear fluid
• Pustule: raised lesion filled with pus

Question 8

What are secondary skin lesions?

Answer 8

• Typically result from evolution of primary lesions, may be initiated by external forces (scratching, infection) or the healing process
• Scale: visible fragments of the stratum corneum as it is shed from the skin
• Crust: liquid debris (serum or pus) that has dried on the surface of the skin
• Lichenification: thickening of epidermis, with resulting accentuation of skin lines, often as a result of scratching
• Fissure: sharply defined, linear or wedge-shaped tears in the epidermis
• Erosion: loss of superficial layers of upper epidermis by friction or pressure
• Ulcer: epidermis and upper dermis have been lost

Question 9

What tools can be used to assess eczema?

Answer 9

• Visual Analogue Scale (0-10) capturing the child/parent/carer’s assessment of severity, itch and sleep loss over the previous 3 days/nights
• Patient Oriented Eczema Measure (POEM)
• Children’s Dermatology Life Quality Index (CDLQI)
• Infants’ Dermatitis QOL Index (IDQOL)
• Dermatitis Family Impact (DFI) questionnaire

Question 10

What do you want to know in a rash history?

Answer 10

• Duration
• Temporal pattern - where did it start and how did it change)
• Distribution
• Associated symptoms
• Exacerbating and relieving factors
• PMH - are any known to be associated with a rash or causing it
• Meds - cause/exacerbate a rash
• FH of rashes/skin problems e.g. psoriasis, eczema
• Is it affecting their work, social activities or other aspects of their lives?
• Do they drink alcohol and if so how much? - alcohol worsens psoriasis or can result in a poorer response to treatment