SKIN EXAMINATION

Comprehensive Guide to Skin Examination

A thorough skin examination is an essential component of clinical assessment, helping to identify dermatological conditions, systemic diseases, infections, and malignancies. This guide will take you step by step through a systematic and detailed skin examination, ensuring accuracy and confidence in your findings.

1. General Considerations Before the Exam

Preparation & Patient Comfort

• Introduce Yourself & Explain the Procedure

  • Let the patient know that a full-skin examination may require exposing different parts of the body.

  • Reassure them that their privacy will be maintained.

• Obtain Informed Consent

  • Ensure the patient is comfortable with the examination process.

• Ensure Proper Lighting

  • Use natural light or a dermatoscope if available, as artificial light can alter skin tone and lesion appearance.

• Ensure Patient Modesty

  • Provide a gown and expose only the area being examined at a time.

2. General Inspection

Start by observing the entire body before moving to localized skin lesions.

Overall Appearance of the Skin

• Color: Assess for normal skin tone variations and any abnormalities like:

  • Pallor → Anemia, shock

  • Cyanosis → Hypoxia, heart/lung disease

  • Jaundice → Liver disease, hemolysis

  • Erythema → Infection, inflammation, drug reactions

• Moisture & Hydration

  • Dry skin → Hypothyroidism, dehydration, eczema

  • Sweaty/clammy skin → Fever, hyperthyroidism, shock

• Texture & Thickness

  • Smooth vs. rough → Thyroid disorders, psoriasis

  • Thin, fragile skin → Aging, Cushing’s syndrome

• Turgor (Elasticity Test)

  • Pinch a fold of skin over the dorsum of the hand or clavicle.

  • Delayed recoil → Dehydration

Distribution of Skin Changes

• Generalized vs. localized involvement

• Symmetry vs. asymmetry

• Sun-exposed vs. covered areas

• Flexural vs. extensor surfaces (e.g., eczema vs. psoriasis)

3. Detailed Examination of Skin Lesions

Primary Lesion Description

Use the SCALDA mnemonic to describe any skin lesion systematically:

S → Size (measure in mm or cm)
C → Color (red, brown, blue, depigmented, etc.)
A → Arrangement (linear, clustered, annular, etc.)
L → Location (specific body part)
D → Distribution (generalized, localized, flexor/extensor, sun-exposed)
A → Associated symptoms (pain, itching, burning, discharge)

Types of Primary Lesions

• Macule: Flat, non-palpable lesion (<1cm) (e.g., freckles)

• Patch: Large macule (>1cm) (e.g., vitiligo)

• Papule: Raised, solid lesion (<1cm) (e.g., warts, moles)

• Plaque: Raised, solid lesion (>1cm) (e.g., psoriasis)

• Nodule: Deep, firm lesion (>1cm) (e.g., lipoma)

• Vesicle: Fluid-filled lesion (<1cm) (e.g., herpes, chickenpox)

• Bulla: Large vesicle (>1cm) (e.g., burns, bullous pemphigoid)

• Pustule: Pus-filled lesion (e.g., acne, folliculitis)

• Wheal: Edematous, raised lesion (e.g., urticaria, insect bites)

Secondary Lesions (Evolved Changes)

• Crust → Dried exudate (e.g., impetigo)

• Scale → Flaky, dry skin (e.g., psoriasis)

• Erosion → Partial epidermal loss (e.g., herpes)

• Ulcer → Full-thickness loss (e.g., pressure ulcer)

• Fissure → Deep linear crack (e.g., athlete’s foot)

• Scar/Keloid → Fibrotic tissue (e.g., surgical scars)

4. Special Examination Techniques

Palpation of Skin Lesions

• Temperature: Use the back of your hand to assess warmth.

  • Increased warmth → Infection, inflammation

  • Cool skin → Poor perfusion, hypothyroidism

• Texture:

  • Smooth and soft → Normal

  • Rough, thickened → Lichenification, chronic eczema

• Mobility & Consistency

  • Freely mobile vs. fixed → To assess for malignancy

• Tenderness & Pain

  • Ask the patient if the lesion is painful or itchy

Nail Examination

• Shape and Color

  • Clubbing → Chronic hypoxia, lung disease

  • Pitting → Psoriasis

  • Spoon nails (Koilonychia) → Iron deficiency anemia

  • Beau’s lines → Severe illness/stress

Hair Examination

• Hair loss patterns

  • Alopecia areata → Autoimmune hair loss

  • Androgenic alopecia → Male/female pattern baldness

  • Telogen effluvium → Post-stress hair shedding

5. Suspicious Skin Changes & Red Flags

• ABCDE Rule for Melanoma

  • Asymmetry

  • Border irregularity

  • Color variation

  • Diameter >6mm

  • Evolution (changing over time)

• Systemic Symptoms Indicating Disease

  • Unexplained weight loss + skin changes → Malignancy

  • Skin changes with joint pain → Lupus, psoriasis

  • Unusual bruising → Hematologic disorder

6. Documentation & Patient Education

• Document Findings Accurately:

  • Describe lesions systematically using SCALDA.

  • Include distribution and associated symptoms.

• Explain Next Steps:

  • If needed, suggest further biopsy, dermoscopy, blood tests, or referrals.

• Preventive Measures:

  • Educate on sun protection, skin hygiene, and regular self-examinations.

7. Pro-Tips to Stand Out in Skin Examination

-Be thorough but efficient → Follow a structured approach.
-Use dermatological mnemonics → (SCALDA, ABCDE) to describe findings precisely.
-Master dermoscopy → If available, use a dermatoscope for a closer assessment of pigmented lesions.
-Correlate systemic diseases → Recognize skin signs of internal diseases (e.g., acanthosis nigricans in diabetes).
-Reassure & Educate the Patient → Patients appreciate a clear explanation of skin conditions and preventive care.