Skin Examination

Question 1

Distribution (general inspection)

Answer 1

Acral - affecting distal areas, hands and feet
Extensor - extensor surfaces, elbows and knees
Flexural - flexural surfaces, axillae, genital areas, cubital fossa
Follicular - arising from hair follicles
Dermatomal - corresponsing with nerve root distribution
Seborrhoiec - associated with areas where there are sebaceous glands, face and scalp

Question 2

Close inspection

Answer 2

Size
Configuration
Colour
Morphology

Question 3

Size

Answer 3

Width
Height (if raised)

Question 4

Configuration - outline of the lesion

Answer 4

Discrete or confluent?
Shape
Border - well defined vs poorly defined

Question 5

Types of configuration

Answer 5

Discrete lesions - individual lesions, clearly separated from one another
Confluent lesions - lesions that appear to be merging together
Linear lesions - e.g. scratching related lesions
Discoid (coin shaped) - discoid eczema / discoid lupus
Target lesions - concentric rings of varying colour - erythema multiforme
Annular - ring like lesions

Question 6

Colour

Answer 6

Erythema - caused by increased blood supply, blanches
Purpura - caused by bleeding, non-blanching (petechiae < 2mm, ecchymosis > 2mm)
Hyperpigmentation - increased melanin production
Hypopigmentation - areas of paler skin to melanocyte or melanin dysfunction or depletion
Depigmentation - skin white due to absence of melanin e.g. vitiligo (autoimmune)

Question 7

Morphology - Primary lesions

Answer 7

Macule - flat area < 1.5cm
Patch - flat area > 1.5 cm
Papule - solid raised lesion < 0.5 cm
Nodule - solid raised lesion > 0.5 cm
Plaque - palpable flat lesion > 1 cm
Vesicle - raised, fluid filled lesion < 0.5 cm
Bulla - raised, fluid-filled lesion > 0.5 cm
Pustule - pus containing lesion < 0.5 cm
Abscess - localised accumulation of pus
Wheal - oedematous papule or plaque caused by dermal oedema
Boil / furuncle - staphylococcus infection around or within a hair follicle
Carbuncle - staphylococcus infection of adjacent hair follicles

Question 8

Morphology - Secondary lesions (modifications of primary lesions that occur due to trauma to or evolution of the primary lesion)

Answer 8

Excoriation
Lichenification 
Scales
Crust
Scar
Ulcer
Fissure
Striae

Question 9

Assesment of a pigmented lesion

Answer 9

Asymmetry
Border irregularity - less defined borders suggestive of sinister pathology
Colour variation or changes - 2 or moer colours more suggestive of sinister pathology
Diameter - change in size? particularly over 6mm
Elevation / evolution - change in colour, size, symmetry, surface characteristics and symptoms (itching, bleeding, scabbing)

If suspicious inspect rest of skin, palpate major lymph nodes of regional drainage area

Question 10

Palpation of lesions

Answer 10

Gloves if infective / likely exposure to body fluids

Surface characteristics - texture, flat / raised / depressed, crust (can it be removed to see what’s underneath), temperature

Deeper characteristics - consistency, mobility, tenderness

Question 11

Nails

Answer 11

Pitting - eczema, psoriasis, alopecia areata
Onycholysis - psoriaiss, fungal nail infection
Koilonychia - IDA, congenital
Clubbing - IBD, CHD, lung cancer, bronchiectasis

Question 12

Elbows

Answer 12

Xanthomas

Psoriasis plaques

Question 13

Hair and scalp

Answer 13

Loss of hair - alopecia areata, alopecia totalis
Excess hair - hirsutism, hypertrichosis
Scalp - psoriasis plaques, dandruff

Question 14

Mucous membranes

Answer 14

Inspect oral cavity for evidence of skin disease e.g. pigmented lesions, bullae