Examining The Skin and Describing Lesions ( 1-4 )
This article aims to take you through the different stages of examining
the skin.
The entire skin surface, as well as hair, nails and mucosal surfaces,
should be examined. In order to carry out the examination, you may require
the patient to undress down to underwear. If the patient has a widespread
rash, it may seem obvious to them that you have to examine their skin in
its entirety.
They may however question the need for a full skin
examination if they present with an isolated lesion. There may be other lesions the patient has not
seen, perhaps on the back or buttocks. It is important to explain this to
the patient without alarming them.
A gown or blanket should be available. The room should be warm with good
lighting. An additional light source and magnifying lens are also useful.
It is important to be aware of, and sensitive to, cultural and religious
differences, and a chaperone may be required in some circumstances.
To make an accurate diagnosis, skin examination should follow a pattern. It is important to carry out the following.
Describing a lesion
Note the distribution and colour of lesions. Are they:
• localised (e.g. a tumour)?
• widespread (e.g. a rash)?
• if widespread, is it symmetrical and, if so, central or peripheral?
• does it involve the flexures (e.g. atopic eczema)?
• does it involve the extensor aspects (e.g. psoriasis)?
• is it limited to sun-exposed sites?
• is it linear?
• is it regional (e.g. groin or axilla)?
• does it follow a dermatomal (corresponding to root nerve distribution) pattern (e.g. shingles)?
Examine the morphology
Examine the morphology (form and structure) of individual lesions. A magnifying lens is helpful.
Consider:
• size
• shape (e.g. linear, grouped, annular, koebner phenomenom
(an inflammatory skin response at the site of previous trauma))
• border change (e.g. pearly edge, rolled edge)
• depth − are lesions dermal or epidermal?
• is it macular (flat) or forming papules?
• is it fluid filled – serous fluid or pus?
• is it indurated (hardened) or forming plaques?
• is it forming crusts, scabs, vesicles: if scaly, does surface flake off easily; if crusted, what is underneath?
• spatial relationship (see below).
Palpate
Palpate to check consistency. This should be done by compressing the lesion between the finger and thumb (in widespread rashes, this may not be necessary):
• soft lesions are easily compressed
• firm lesions can only just be compressed
• hard lesions cannot be compressed
• is it raised?
• is it irregular?
• what is the texture?
Describe colour
If the lesion is non-erythematous, describe changes in colour:
• pink, red, purple, mauve – due to blood
• brown, black, blue – due to pigment
• white – due to lack of blood/pigment
• yellow, orange – lipids or bilirubin.
Other considerations
These would include:
• is there sensitivity to touch – pain, tingling or itch?
• is there odour, which may be indicative of infection?
• is the affected skin hot or cold to the touch, compared to another area of the skin which is not involved – infection/inflammation should be a consideration.
Examine nails etc.
Examine and assess nails, hair, scalp, and mucous membranes:
• nails – observe colour and shape, check capillary return, look pigment changes or longitudinal lines
• hair and scalp – check for scale, erythema, hair loss
• mucous membranes – blistering, erosions, scarring.
Investigations
The investigations listed below are regularly carried out in dermatology departments. Some, such as skin biopsy, may not be available in your clinical setting. If your assessment indicates that more specialized investigations are required, refer the patient to a dermatology department.
• Swab for bacterial investigations – ensure swab tip is moistened, roll swab in a zig-zag motion rotating between fingers.
• Swab for viral investigations – pierce vesicle and swab fluid inside.
• Mycology for fungal or yeast infection investigations – skin scrapings, nail clippings, hair debris.
• Common blood tests performed in dermatology (below).
• Photography.
• Woods lamp – identifies bacterial or yeast infections.
• Diagnostic biopsy – to help confirm histological changes.
A general physical examination including height, weight, temperature and cardiovascular/respiratory assessment may also be required if indicated by symptoms or clinical signs.
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