Clinical Assessment- Dermatology

Functions of the integumentary system

-Protection

-Lipid storage

-Coordination of immune response

-Sensory information

-Vitamin D3 synthesis

-Excretion

-Thermoregulation

Parts of the integumentary system

-Epidermis

-Dermis (papillary layer and reticular layer)

-Hair follicles

-Exocrine glands

-Nails

2 layers of the dermis

Papillary Layer and Reticular Layer

Cells in the Epidermis

-Keratinocytes

-Melanocytes

-Langerhan's cells

Layers of the Epidermis (Superficial to Deep)

-Stratum corneum

-Stratum lucidum

-Stratum granulosum

-Stratum spinosum

-Stratum basale

-Basement membrane

How thick is the dermis?

1-4 mm

The ______________ contains blood vessels, lymphatic vessels, nerves, hair follicles, sweat glands, fibroblasts, and mast cells

Dermis

What do fibroblasts do?

Make and break down connective tissue proteins

What do mast cells do?

Involved in immune response to form allergy type symptoms

What is the subcutis (panniculus)?

Adipose layers that separate the dermis from fascia and muscles

What is a pilosebaceous unit?

A hair follicle, sebaceous gland, apocrine sweat gland, and arrector pili muscle

What does decreased skin turgor indicate?

Dehydration

What are examples of alarm symptoms?

-Diffuse erythema

-Fever

-Rapid evolution

-Blistering

-Grey/Purple/Dusky skin

-Sloughing

-S/s of anaphylaxis

Why are Wood's Lamps used?

-Disorders of pigmentation like melasma or vitiligo

-Tinea versicolor

-Tinea capitis

-Scabies or head lice

-Pseudomonas

What does Tinea Versicolor look like under a Woods Lamp?

May emit an orange glow

What does Tinea Capitis reveal under a Woods Lamp?

-Areas of baldness

-Blue-green glow if microsporum species

What does Pseudomonas look like under a Woods Lamp?

Fluorescent green

What is diascopy?

Firmly pressing a microscopic slide/glass spatula over a skin lesion to determine whether the red color of a macule or papule is due to capillary dilation or extravasation of blood that does not blanch

What is a KOH prep?

Potassium hydroxide prep used to microscopically identify fungi or yeast

What is dermoscopy?

Using a hand-held lens with magnification (a dermatoscope) to inspect deeper layers of the epidermis non-invasively

Can be used to distinguish between benign and malignant growth patterns in pigmented lesions

What is confocal microscopy?

A non-invasive imaging technique that enables in vivo visualization of the epidermis down to the papillary dermis in real-time

What patient positioning is best for a full skin examination?

Prone

What is a macule?

A flat, non-palpable lesion less than 1.0 cm in size

What is a papule?

A raised, palpable growth less than 1.0 cm in size

What is a plaque?

A raised, palpable growth greater than 1.0 cm in size

*Number and location are keys to diagnosis

What is a nodule?

A raised, solid lesion greater than 1.0 cm that may occur in the epidermis, dermis, or subcutaneous tissue

What is a vesicle?

A fluid filled, raised growth less than 1.0 cm in size

What is a bulla?

A raised, fluid filled growth greater than 1.0 cm

What is a pustule?

A papule with a pus filled center

What is a wheal?

Compressible, raised edema that is typically itchy-- hives

What is a scale?

Flakes of cornified skin layer

What is an erosion?

Loss of superficial epidermis with little to no bleeding

What is an ulcer?

Loss of the epidermis and dermis

What is a region of excoriation?

A region of ulceration that has been caused by scratching; is often linear

What is a region of lichenification?

An area of thickened, leathery skin that results from chronic rubbing or scratching

What is a fissure?

A crack in the skin

What is a telangiectasia?

An area of prominent blood vessels

What is a patch?

A flat, non-palpable lesion > 1.0 cm in size

What is a cherry angioma?

A benign, tiny, vascular growth that occurs with aging

What are petechiae?

Pin point (1-2 mm) red or purple papule or macule caused by hemorrhage

What are purpura?

Non-palpable, non-blanching violaceous discoloration of the skin

What is ecchymosis?

Individual bruising

What is a tumor?

A solid mass, larger than 1.0 cm

What is atrophy?

Loss of some portion of the skin

What does serpiginous mean?

Snake-like

What does annular mean?

Circular with central clearing

What does umbilicated mean?

Having a central dimple

What does morbilliform mean?

Rosy, maculopapular

What are examples of macules?

-Nevi

-Melanomas

-Superficial basal cell carcinomas

-Freckles

-Lentigines

What are examples of patches?

-Melanoma

-Cage au lait spots

-Vitiligo

-Superficial basal cell carcinomas

What are examples of papules?

-Nevi

-Neurofibromas

-Cherry angiomas

-Seborrheic keratoses

-NMSCs

-Nodular melanomas

-Actinic keratoses

-Dermatofibromas

What are examples of plaques?

-Non-melanoma skin cancers

-Psoriasis

-Eczema

-Lichen simplex chronicus

-Granuloma annulare

What are examples of pustules?

-White heads

What are examples of vesicles?

-Herpes

-Chicken pox

-Contact dermatitis

What are examples of nodules?

-Cysts

-Lipomas

What are examples of bulla(e)?

-Blisters

What are spider angiomas?

A telangectasia with a central red circle and small vessels branching from it

What are the 4 phases of the hair growth cycle?

1. Anagen--> growth phase

2. Catalan--> transition phase

3. Telogen--> exogenous shedding phase

4. Hair falls out and new anagen forms

90% of hairs on the scalp are in what growth phase?

Anagen phase

What is the male androgenetic hair loss pattern?

Frontal receeding, hair loss around the temples, formation of an "M" shape

What is the female androgenetic hair loss pattern?

Gradual thinning from the crown down

What is areata?

Sudden onset of well defined, localized round or oval patches of hair loss without scarring

What is the most common infection of the hand?

Paronychia

What is clubbing?

Bulbous swelling of the soft tissue at the nail base with loss of the normal angle between the nail and the proximal nail fold

What is melanonychia?

Pigmented streaks in the nail plate

What is onycholysis?

A painless separation of the whitened opaque nail plate from the pinker translucent nail bed

What is onychomycosis?

Most common fungal infection of the nail plate that causes nail thickening and subungual debris

What is Hutchinson's sign?

Pigment changes in the eponychium seen with subungual melanoma

What is the best prevention of Onychonycosis?

Treat and prevent tinea pedis

What are risk factors for melanoma?

-Red or blonde hair

-Light (blue/green) eyes

-Easily burnt/history of sunburns

-Family history of skin cancer

-History of pre-cancers or actinic keratoses

-History of UV exposure

-High number of nevi

What is the biggest cause of skin cancers?

UV radiation

What are the ABCDEs of melanoma?

-Asymmetry

-Borders, irregular

-Color, dark black/multicolored/red and pigmented

-Diameter, > 5 mm

-Evolving

What is the EFG criteria for nodular melanomas?

-Elevated

-Firm

-Growing/continuous growth for 1 month

What are the ABCDs of pediatric melanoma?

-Amelanotic

-Bleeding bump

-Color uniformity

-Any diameter

Why and when is local anesthesia used during dermatology procedures?

Provides reversible blockade of nerves leading to loss of pain sensation

Used in repair of lacerations, skin surgery, treatment of painful oral or genital lesions, and in removal of superficial lesions

Are amides long or short acting?

Long acting

Are esters long or short acting?

Short acting

Where are amides metabolized?

Liver

Where are esters metabolized?

Plasma and tissue fluids

Where are amides excreted?

In the urine

Where are esters excreted?

Urine

What are examples of amides?

-Lidocaine

-Bupivacaine

-Mepivacaine

-Prilocaine

What are examples of esters?

-Benzocaine

-Procaine

-Cocaine

-Tetracaine

Why is epinephrine added to lidocaine?

Increases lidocaines duration of action by 60-180 minutes

What does epinephrine do?

Aids with vasoconstriction, reduces systemic absorption of the amide/ester it is combined with, and shortens the onset of action

What are absolute contraindications to epinephrine use?

-Untreated hyperthyroidism or pheochromocytoma

-Severe hypertension and CAD

-Periorbital infiltration in patients with narrow angle glaucoma

-Patients taking ergot-containing medications

What are side effects of epinephrine use?

-Cardiac dysrhythmia

-Increased blood pressure

-Anxiety

-Ischemia

*Mainly occur due to injection directly into a vessel

What can be used as a buffer to prevent burning with local anesthetic use?

Sodium chloride

*Can degrade epinephrine

What are common side effects of allergies/sensitivities to local anesthetics?

-Bruising

-Edema

-Prolonged nerve damage

-Temporary motor nerve paralysis

Why are skin biopsies done?

To determine the cause of a lesion or condition, to remove a lesion, or both

What are the types of skin biopsies?

-Shave

-Saucerization (deep shave)

-Punch

-Incisional

-Excisional

What is a shave biopsy?

The horizontal shave of a skin lesion that can be superficial or deep

What conditions indicate a shave biopsy?

*Good for elevated lesions

-Skin tags

-Papillomatous nevi

-SKs

-Areas of tension

-Areas where hypertrophic scars are common

When should shave biopsies not be used?

When a patient is on a blood thinner, has a defibrillator, or pacemaker

What is saucerization?

A "scoop shave"; tangentially removing a lesion in its entirety by extending more deeply into the dermis and providing clinically clear 1-2 mm margins

Saucerization is considered a _____________ biopsy

Excisional

What is the gold standard for biopsy of melanomas?

Excisional biopsy; allows the entire lesion to be examined

Punch biopsy is considered a _____________ biopsy

Incisional

When are sutures indicated?

-Hemostasis

-Reduce likelihood of infection

-Decrease amount of scar tissue

-Repair loss of structure, function, or both

-Improve cosmetic appearance

To minimize infection and scar potential, wounds should be closed within _____________ of the injury

8 hours