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ApproachtothePatientwithDermatologicDiseaseDermatologyMKSAP17

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Chapter01:ApproachtothePatientwithDermatologicDisease
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ApproachtothePatientwithDermatologicDisease

Introduction
Skinconditionsaccountforasubstantialnumberofphysicianvisits,withpatientspresentingto
internistsforevaluationandmanagementofprimarydermatologicissues,theskin
manifestationsofinternaldisease,orcutaneousadversereactionsfromtherapeuticregimens.
Thus,theabilitytorecognizecommonskinfindingsandthecutaneouscluesassociatedwith
underlyingdisordersortheirtreatmentisanimportantskillrequiredofinternists.Thissection
willcoverkeyaspectsofdermatologyfortheinternist,withanemphasisondiagnostic
recognition,earlyevaluation,andinitialmanagement.Thiswillalsoincludeafocusonwhen
torefer,withanemphasisonrecognizingkeycutaneoussignsthatsuggestapatientmaybe
moreacutelyillorrequireamorethoroughevaluationandconsultationwithanexperienced
dermatologist.

PhysicalExamination
RelatedQuestion
Question20
TheU.S.PreventiveServicesTaskForce(USPSTF)statesthatthereisinsufficientevidenceto
recommenddedicatedscreeningforskincancerinthegeneralpopulation.However,thereisa
growingbodyofevidencesuggestingthatpatientswhoarescreenedhaveearlier,moretreatable
skincancers,andthatcounselingthesepatientsaboutpreventivemeasuresandselfexamination
canreducethenumberorseverityofskincancersandleadtoearlierdetection.Asensible
approachinaverageriskpatientsistoperformanintegratedskinexamination,evaluatingthe
skinduringthecourseoftheroutinephysicalexamination.Whilecheckingbloodpressureand
pulse,lookatthearmswhileexaminingtheabdomen,lookattheskinofthetorsoandwhile
listeningtothelungs,lookattheback.Highriskpatientsmaywarrantmorecomprehensiveand
regularevaluation(Table1).Acomprehensiveskinexamination,whichtakesonaverageonly1
to2minutes,shouldincludeevaluationofthescalpbelowthehair,themucosa,andthegenitals,
includinglookingbetweenskinfolds,digits,andonthesolesofthefeet.Patientsshouldbe
counseledabouthowtoperformskinselfexaminations(generallydoneoncemonthly,ina
systematicfashion)andtousesunprotection(Table2).
Table1.OpeninNewWindowSkinCancer
RiskFactorsThatWarrantRegularSkin
CancerScreening
Historyofmultipleblisteringsunburns
Redorlighthairlightcoloredeyes

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Redorlighthairlightcoloredeyes
Multipleatypicalnevi
Historyofmelanoma
Historyofnonmelanomaskincancers
Familyhistoryofskincancersormelanoma
Immunosuppression
Historyofphototherapy
Table2.OpeninNewWindowSunProtection
Usebroadspectrumultravioletprotectivesunscreen
Usechemicalorphysicalsunblockingagents(orcombination)
UseSPF15orgreater
Apply30minutesbeforesunexposure,reapplyevery2hoursmorefrequentlyifwet
Avoidthepeakhours(11AMto2PM)
Considerultravioletprotectiveclothing
SPF=sunprotectionfactor.
Thelanguageofdermatologyisoftenapointofconfusionformanyinternists,butrecognizing
anddescribingprimarylesionsiscriticaltoforminganaccuratedifferentialdiagnosisandcan
helpdermatologiststriagereferredpatientsbasedontheacuityoftheirlesions.
Theprimarylesionreferstothemorphologyofaskineruptionasitfirststartsandisan
essentialcluetoaspecificdiagnosis.Lesionsoftenevolveovertimeandmaycausesecondary
changestotheskin,eitherduetotheprocessitselfortoexternalfactorssuchastraumaand
scratchingthesefindingsarecalledsecondarylesions(Table3).Whendescribingskin
lesions,focusonthecolor,location,anddistributionofthelesion,includingtheprimary
morphology.Erythemaimpliestransientrednessoftheskinduetoinflammationthatblanches
orlightenswithpressure.Itisoftenessentialtodistinguisherythemafromnonblanching
purpura,whichimpliesdamagetovesselsandasubstantiallydifferentdifferentialdiagnosis.

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Table3.OpeninNewWindowLesionMorphology

Primary
Lesions

Description

Smallsize,flat,changeinskincolor
Macule

Circular,oval,orirregular
Bordermaybedistinctorgraduallyfadetonormalskin

Patch

Largerthanamacule,1cmorlarger
Mayhaveveryfaintfinescaleorminimalsurfacechange

Smallbumps,frompinpointto1cm
Papule

Discreteraisedlesions
Lackfluidorpus
Maybeflat,umbilicated,grouped,filiform,orscaly

Maculopapular

Aneruptionwithoverlappingmorphologies
Admixtureofsmall,flatareaswithpinpointslightlyraisedbumps

Largerraisedlesion,1cmorlarger
Plaque

Oftenflattopped
Likeaplateau

Largerthanapapule
Nodule

Usuallyindistinctborders
Oftenarisesdeeperundertheskinandpushesup

Transient,edematous,erythematousplaques
Wheal

Oftenoval,arcuate,serpiginous,circular
Hives

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Small,fluidfilledpapules,rangingfrompinpointto1cm
Vesicle

Oftentranslucentorslightlyyellow
Whitishvesiclesaretermedpustules

Largerthanvesicles,often1cmorlarger
Bullae

Maybethinwalledandruptureeasily(flaccid)ortensewiththickertop
(tense)
Blisters

Secondary
Lesions

Scale

Description

Excesskeratinfromstratumcorneum
Maybeafinedusting,amoistgreasyscale,orathicksilveryscale

Driedoutserum,blood,orinflammatorycells,oftenmixedwithepidermisand
surfacebacteria
Crust

Maybehemorrhagic(fromblood),orangeyellow(fromserumor
Staphylococcuscolonization),orthickandblack(escharfromchronicwound)
Ulcersmaydevelopafibrinousbiofilmwithpolymicrobialcolonization,which
mayrepresentamoistcrust

Excoriation

Linearerosions,oftencrusted,maysuggestexternaltraumaandscratchingthat
canleadtolossoftheepidermis

Linearcrackexposingdermis
Fissure

Erosion

Generallyoccurswhereskinismoistandmacerated,suchasfolds,orwhere
skinisverythickandrigid,suchastipsoredgesofacralsites

Lossoftheepidermisaloneleadstoasmall,oftenpunchedout,shallow,
moistdepression
Healswithoutscarring

Completelossoftheepidermisintothedermis

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Completelossoftheepidermisintothedermis
Ulcer

Canbevaryingdepths,includingtodeepertissuesinthesubcutis
Healswithscarring

Skindamagedbeyondthebasementmembraneoftheepidermiswillgenerally
Scar

healwithscarring
Certainanatomicsitesandsomeblackpersonsaremorepronetothicker
scarring

Itisnotuncommonforpatientstohavepicturesoftheirlesionsorforphysicianstohaveaccess
tomobiledevicesthatallowphotographyandimagetransmission.Physiciansshouldbe
cautiousintakingpicturesandsendingthemandmustensurethatanypatientphotographyis
protectedaspatientinformationandsentonlythroughsecuretelecommunicationservicesoras
encryptedemail.Photographsarepartofthepatient'smedicalrecord,andcopiesofallpictures
shouldbemaintainedwiththepatient'schart.Whereasteledermatologyisavaluabletooland
holdspromiseforexpandingaccessinthefuture,studiesareongoingtodeterminetheaccuracy
ofteledermatologyfortriageandpatientmanagement,andatthistimemostinsurersdonot
reimburseforteledermatologyservices.
Asinallofmedicine,aprimaryresponsibilityistodeterminethelevelofacuityofadisorder
andwhetherapatientrequiresimmediateinterventionorahigherlevelofcare.Thisholdstrue
fordermatologyaswell,andalthoughmostdermatologicdiseaseslackurgency,somedisorders
representtrueemergencies(Table4).
Table4.OpeninNewWindowDermatologicEmergencies
Widespreaderythemaorerythroderma(drugeruption,bacterialtoxinmediateddisease,severe
psoriasis)
Highfeverandwidespreadrash(severedrugeruptions,rickettsialdiseases)
Diffusepeelingorsloughingofskin(toxicepidermalnecrolysis,infection)
Dark,dusky,purpleareasofpainfulskin(impendingskinlossfrominfectionorseveredrug
eruption)
Mucosalinflammation,erosions,orulceration(severedrugeruption,autoimmuneblistering
diseasewithhighriskofmorbidscarring)
Widespreadblistering(autoimmuneblisteringdisease,infection,severedrugeruption)
Purpura,particularlyretiformorlacey,patternedpurpura(vasculitis,vasculopathy,infection,
autoimmunedisease)
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Broadareasofexquisitelypainfulskinoutofproportiontoclinicalexaminationfindings
(necrotizingfasciitis)
Angulatedpurpuraofthedistalextremities(sepsis,autoimmunephenomena)
Palpablepurpura(smallvesselvasculitisfrominfection,medications,orautoimmune
reactions)
Immunosuppressed,particularlypatientswithneutropenia,withskinlesionsofunknowncause
inthesettingoffever,particularlyredorpurplenodules(skinsignsofinfectionin
immunosuppressedhosts)
Purpleornecroticskinlesionsinimmunosuppressedhosts(angioinvasivefungalinfection)
Rapidlygrowinglesionsinimmunosuppressedhosts(infection,malignancy)
Worrisomepigmentedlesionswarranturgent(notemergent)referralandevaluation
(melanoma)

KeyPoints
Screeningforskincancerinpatientswhoareatincreasedriskmayallowfordiagnosisat
amoretreatablestage.
Foraverageriskpatients,anintegratedskinexaminationinvolvesevaluatingtheskin
forabnormalitiesduringthecourseoftheroutinephysicalexamination.

Bibliography
AshtonRE.Teachingnondermatologiststoexaminetheskin:areviewoftheliterature
andsomerecommendations.BrJDermatol.1995Feb132(2):2215.PMID:7888358
ChoudhuryK,VolkmerB,GreinertR.ChristophersE,BreitbartEW.Effectivenessofskin
cancerscreeningprogrammes.BrJDermatol.2012Aug167Suppl2:948.PMID:
22881593
WolffT,TaieE,MillerT.Screeningforskincancer:anupdateoftheevidencefortheUS
PreventiveServicesTaskForce.AnnInternMed.2009Feb3150(3):1948.PMID:
19189909
ThiscontentwaslastupdatedinAugust2015.

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