Introduction to DERMATOLOGY &

assessment of a dermatology
patient

Prof. Tariq Mahmood

• largest organ of the body
• exposed organ
• affected in many systemic disorders
• Skin diseases form a substantial
part (about 20%) of everyday
general practice
 General aspects of skin

• 16% of the body weight.

• Surface area 1.7 m2
• 1.5-4.0 mm thickness
• identical manifestation - different
diseases
• Same etiologic factors – diversity of
eruptions
• Advantage – exposed organ
– Seen and felt
– Smear and cultures
– Biopsy and histological examination
 Histopathology
Comprises of 3 layers
• Epidermis
• Dermis
• Hypodermis
 Epidermis
• Thickness 0.1-1.5mm
• Thickest on palms &
soles thinnest on
eyelids
• 5 layers
– Stratum basale
– Stratum spinosum
– Stratum granulosum
– Stratum lucidum (palms
& soles)
– Stratum corneum
Types of cells
– Keratinocytes (>90% of cells)
– Melanocytes
– Langerhans cells
– Merckel cells
 Melanocytes
• Dendritic cells
• Present in the
basal layer
• One melanocyte
distributes melanin
to 35 surrounding
keratinocytes
 Langerhans cells
• Dendritic cells of
bone marrow origin
• Present antigens to
T lymphocytes
 Dermis

• Cells: fibroblasts, histiocytes, mast cells etc.

• Fibers: collagen, elastic fibers, reticulin fibers
• Sweat glands
– Eccrine
– Apocrine
• Sebaceous glands
• Hair follicles
• Smooth muscles: arrector pili, blood vessels,
dortos
• Blood vessels
• Lymphatics
• Nerves
 Cells
in
dermis
 Fibres &
ground
substance
 Hair &
Sebaceous glands
• 5 million hair on body
• 100,000 on scalp
• Grow in phases
• Associated with
sebaceous glands,
arrector pili, apocrine
glands
 Functions

• Protection: against mechanical, microbial,

physical or chemical injury
• Perception: touch, pain, temperature
• Heat regulation: by sweating
• Excretion: urea, lactic acid etc.
• Synthetic: vitamin D
• Aesthetic function
• Emotional: flushing in anger
BASIC SKIN LESIONS
 PRIMARY LESIONS

MACULE

Discoloration of skin < 1cm

PATCH
Discoloration of skin > 1cm
PAPULE
Palpable lesion < 1cm
PLAQUE
Palpable lesion > 1cm
NODULE

Circumscribed swelling

within the substance of

skin
WEAL

Transient swelling due to

edema of skin (dermis)

VESICLE

Fluid containing lesion < 1cm

BLISTER

Fluid containing lesion > 1cm

PUSTULE

Pus containing lesion

OPEN COMEDO

Primary lesion of ACNE

Keratin Plug filling dilated
central opening
CLOSED COMEDO
BURROW
pathognomonic lesion of
scabies

(grayish linear, C or S-
shaped raised lesion
at characteristic sites)
 SECONDRY LESIONS

CRUST

Dried up serum, pus or

blood
SCALE

Desquamating horny

flakes due to abnormal

keratinization
ICHTHYOSIS

Pattern of skin resembling

fish scales
EXCORIATIONS

Linear marks produced

by scratching
EROSION

Superficial break in skin

involving epidermis
ULCER

Raw Area Resulting from

loss of skin surface

FISSURE

Crack in skin when it

becomes thick &

inelastic
SCAR

Fibrous tissue

replacement of normal

skin
ERYTHEMA

Redness due to dilatation

of blood vessels
TELANGIECTASIA

Pattern produced by

permanently dilated

blood Vessels
PURPRA

Circumscribed spots due

to leakage of blood in

dermis
ECCHYMOSIS

Diffuse leakage of blood in

dermis on a larger scale

 Lichenification
• Thickening
• Leathery
consistency
• Hyperpigmentation
• Associated with
severe itching
 DERMATOLOGICAL HISTORY
• Standard structure
• Presenting complaints (nature, site, and duration
of problem)
• History of presenting complaint
– Initial appearance and evolution
– Symptoms (e.g. itching, pain)
– Aggravating & relieving factors
– effect of treatment
– Contact, stress, illness, travel
• past history
– h/o atopy – rhinitis, eczema
– Suspicious skin lesions
– Skin malignancy
– h/o sunburn
• family history
− Family history of skin diseases
• social history
– Occupation
– Improvement when away from work
• medication & allergies
– Regular, recent & OTC medication
• impact on QOL
 EXAMINATION OF SKIN

• Examination Well-lit room

– Magnifying glass
– Palpation – firmness and fluctuation
– rubbing and scraping
– Diascopy
– Entire eruption should be seen
 Examination of skin

• Inspection
• Description
• Palpation
• Systemic examination
 INSPECTION

• General observation
• Site and number of lesions (Single or
multiple)
• If multiple - pattern of distribution and
configuration
Description of individual lesion
• Size
• Shape
• Color
• Secondary change
• Morphology, margins
• Evolution
– fully evolved
– Crops – polymorphous
• Involution
– Complete
– Scarring
– Dyspigmentation
• Grouping
PALPATION of individual lesions

• Surface
• Consistency
• Mobility
• Tenderness
• Temperature
• Anaesthesia
 SYSTEMIC CHECK

• Scalp
• Hairs
• Nails
• Oral mucosa
• General examination of all systems
 General Terms
• Pruritus – itching
• Lesion – an area of altered skin
• Eruption – Rash
• Naevus – A localized malformation of tissue
structures
 Distribution
• Flexural – body folds (groins, neck, behind
neck, popliteal and antecubital fossa
• Pressure Area –sacrum, buttock, ankles,
heels
• Extensor surfaces – knees, elbows, shins
• Photosensitive – sun exposed ( face, neck ,
back of hands)
• Koebner phenomenon – An eruption at site of
trauma
• Few or numerous
• Generalized – all over body
• Localized – Restricted to one area of
skin
• Widespread – extensive
• Bilaterally symmetrical
• Dermatome – an area of skin supplied
by a spinal nerve
Configuration
(Pattern and shape of grouped lesions)

• Discrete – individual lesions separated from each

other
• Confluent – individual lesions merging together
• Linear – in a line
• Target lesions
• Annular lesions
• Discoid / Nummular lesions
• Arcuate & Polycyclic
• Guttate
• Evolution
– fully evolved
– Crops – polymorphous
• Involution
– Complete
– Scarring
– Dyspigmentation
• Grouping
• Color
– Violaceous –Lichen planus
– Yellow -Xanthomas
– Pinkish violet - dermatomyositis
– Hypopigmented
– depigmented