13/5/2014 Approach to dermatologic diagnosis

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Official reprint from UpToDate
www.uptodate.com 2014 UpToDate
Authors
Beth G Goldstein, MD
Adam O Goldstein, MD, MPH
Section Editors
Robert P Dellavalle, MD, PhD, MSPH
Moise L Levy, MD
Deputy Editor
Rosamaria Corona, MD, DSc
Approach to dermatologic diagnosis
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Apr 2014. | This topic last updated: Aug 07, 2012.
INTRODUCTION Approximately 7 percent of all adult outpatients have a primary skin complaint, and 60 percent of
outpatient visits for skin disease are made to nondermatologists [1]. Patients with common, chronic medical conditions,
such as obesity and diabetes, have increased numbers of skin conditions [2,3]. The prevalence of skin conditions is high
even among hospitalized patients, with many previously undiagnosed conditions becoming manifest upon a thorough skin
examination [4]. Over 12 million physician office visits are made by adolescents and young children for skin concerns [5].
More than one-half of patients also have great interest in skin care products or use alternative treatment modalities that may
impact the skin, such as herbs and food supplements [6].
Some research suggests that the training of primary care physicians in dermatologic diagnosis and treatment is insufficient
compared with that delivered by dermatologists [7]. Nevertheless, patients trust that their primary care clinician will
accurately diagnose and treat the majority of their skin conditions, even while they have higher trust in the diagnostic
acumen of the dermatologist [8]. Thus, primary care clinicians need an ever increasing base of knowledge, awareness, and
diagnostic skill in dermatology.
Being able to speak the language of dermatology is half the battle. Once you can identify the primary and secondary
characteristics of a skin lesion, you will achieve far more success in formulating an appropriate differential diagnosis. The art
and science of dermatologic diagnosis lies in utilizing all available findings to assist in forming and then narrowing the
differential diagnosis [9,10]. Unlike many diseases, objective findings are present the majority of the time in locations
detectable upon physical examination.
The initial approach to the patient presenting with a skin problem requires a detailed history of the current skin complaint
and a complete skin examination (figure 1A-B). In many cases the patients general medical history may be relevant to the
diagnosis of skin disorders.
HISTORY The most important initial questions to ask patients with a skin problem include the following:
How long has the rash/lesion been present?
How did it look when it first appeared, and how is it now different?
Where did it first appear, and where is it now?
What treatments have been used, and what was the response, this time and previously?
What associated symptoms, such as itching or pain, are associated with the lesion?
Are any other family members affected or have a similar history?
Has the patient ever had this rash before? If so, what treatment was used/response?
What does the patient think caused the rash?
Is anything new or different, ie, medications, personal care products, occupational or recreational exposures?
Additional questions that may be helpful include:
Does the patient have any chronic medical conditions?
What medications does the patient take currently, what have they recently taken, including over-the-counter and
herbal therapies?
Has there been any increase in stress in their life?
What is the social history, including occupation, hobbies, travel?
Does the patient have any underlying allergies?

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Will the patient's education, insurance, or financial status influence treatment considerations, such as compliance?
PHYSICAL EXAMINATION On physical examination, it is important to include characteristics such as distribution
(extensor surfaces in psoriasis and dermatitis herpetiformis), lesion morphology (wheals, macules, papules), and secondary
characteristics of lesions (thick, silvery scale, thickening, or lichenification). Knowing which conditions are more frequently
diagnosed can assist the practitioner in arriving at the most likely diagnosis for a given patient. A table shows the top 10
most common diagnoses for patients presenting to dermatologists and nondermatologists for skin problems (table 1).
The physical examination of skin complaints should include the following:
Type of lesion
Shape of individual lesions
Arrangement of multiple lesions (eg, scattered, grouped, linear, etc.)
Distribution of lesions
Color
Consistency and feel
The two most useful characteristics in terms of forming a differential diagnosis are the type and distribution of lesions.
Lesion type It is important to always accurately describe dermatologic lesions. Many diseases are more easily identified
when the appropriate morphology is recognized. As an example, isolated macular eruptions are rather infrequent compared
to papular or papulosquamous conditions. Thus, if hyperpigmented or hypopigmented macules are seen in isolation, the
differential diagnosis is much smaller (see "Approach to the patient with macular skin lesions"). True bullae also occur less
frequently than vesicular and pustular eruptions. (See "Approach to the patient with cutaneous blisters" and "Approach to the
patient with pustular skin lesions".)
Primary lesions Primary lesions are either the first visible lesion or involve the initial skin changes. The terms used to
describe primary skin lesions include the following:
Macules are nonpalpable lesions that vary in pigmentation from the surrounding skin (picture 1A-B). There are no
elevations or depressions. The differential diagnosis of macules is shown in a table (table 2).
Papules are palpable, discrete lesions measuring 5 mm diameter (picture 2). They may be isolated or grouped. The
differential diagnosis of papules is shown in a table (table 3).
Plaques are large (>5 mm) superficial flat lesions, often formed by a confluence of papules (picture 3). The differential
diagnosis of plaques is shown in a table (table 4).
Nodules are palpable, discrete lesions measuring 6 mm diameter (picture 4). They may be isolated or grouped.
Tumors are large nodules. The differential diagnosis of tumors and nodules is shown in a table (table 5). (See
"Overview of benign lesions of the skin".)
Cysts are enclosed cavities with a lining that can contain a liquid or semisolid material (picture 5).
Telangiectasia is a dilated superficial blood vessel (picture 6).
Pustules are small, circumscribed skin papules containing purulent material (picture 7). The differential diagnosis of
pustules is shown in a table (table 6).
Vesicles are small (<5 mm diameter), circumscribed skin papules containing serous material (picture 8). Bullae are
large (6 mm) vesicles. The differential diagnosis of vesicles and bullae is shown in a table (table 7).
Wheals are irregularly elevated edematous skin areas that are often erythematous (picture 9). The borders of a wheal
are sharp but not stable; they may move to adjacent uninvolved areas over periods of hours.
Secondary lesions Secondary lesions of the skin represent evolved changes from the skin disorder, due to
secondary manipulation or as a result of infection. Examples include:
Excoriation describes superficial, often linear, skin erosion caused by scratching (picture 10).
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Lichenification is increased skin markings and thickening with induration secondary to chronic inflammation caused
by scratching or other irritation (picture 11).
Edema is swelling due to accumulation of water in tissue (picture 12).
Scale describes superficial epidermal cells that are dead and cast off from the skin (picture 13).
Crust is dried exudate, a "scab" (picture 14).
Fissure is a deep skin split extending into the dermis (picture 15).
Erosion is a superficial, focal loss of part of the epidermis. Lesions usually heal without scarring (picture 16).
Ulceration is focal loss of the epidermis extending into the dermis. Lesions may heal with scarring (picture 17). The
differential diagnosis of erosions and ulcers is shown in a table (table 8).
Atrophy is decreased skin thickness due to skin thinning (picture 18).
Scar is abnormal fibrous tissue that replaces normal tissue after skin injury (picture 19).
Hypopigmentation (picture 20A) is decreased skin pigment; hyperpigmentation (picture 21) is increased skin pigment;
and depigmentation (picture 20B) is total loss of skin pigment.
Lesion location Certain conditions have a predilection for particular parts of the body and are seen in characteristic
demographic groups. As an example, tinea capitis is a common scalp eruption in children but is rare in adults. In contrast,
tinea pedis is seen frequently in adults but rarely in children. Thus, when a child presents with foot lesions, diagnoses in
addition to tinea must be considered, including eczema or atopic dermatitis, drug eruptions, and contact dermatitis. When
an adult presents with a scalp eruption, do not assume there is a tinea infection, but consider whether the patient has
seborrheic dermatitis, psoriasis, or an allergic dermatitis.
A table lists initial differential diagnoses based upon classical distributions of common skin dermatoses (table 9); this is
shown graphically in figures (figure 1A-B).
SUMMARY
The initial approach to the patient presenting with a skin problem requires a detailed history of the current skin
complaint and a complete skin examination (figure 1A-B). In many cases the patients general medical history may
be relevant to the diagnosis of skin disorders. (See 'Introduction' above.)
Key questions for the patient include the time of onset, duration, location, evolution, and symptoms of the rash or
lesion. Additional information on family history, occupational exposures, comorbidities, medications, and social or
psychological factors may be helpful. (See 'History' above.)
The type, shape, arrangement, and distribution (table 9) of the lesions are cardinal features to be identified by visual
inspection and palpation. Primary lesions and related diagnoses include (see 'Primary lesions' above):
Macules (picture 1A-B and table 2)
Papules (picture 2 and table 3)
Plaques (picture 3 and table 4)
Nodules (picture 4 and table 5)
Cysts
Telangiectasia (picture 6)
Pustules (picture 7 and table 6)
Vesicles and bullae (picture 8 and table 7)
Wheals (picture 9)
Secondary changes are due to spontaneous evolution, manipulation, superimposed infection, or previous treatment
and may alter the morphology of the primary lesion. Secondary lesions include (see 'Secondary lesions' above):
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Excoriation (picture 10)
Lichenification (picture 11)
Edema (picture 12)
Scale (picture 13)
Crust (picture 14)
Fissure (picture 15)
Erosions and ulcers (picture 16 and table 8)
Atrophy (picture 18)
Scar (picture 19)
Hypopigmentation (picture 20A-B) and hyperpigmentation (picture 21)
The lesion location often provides a clue to diagnosis, since many skin disorders have a predilection for particular
body sites (figure 1A-B and table 9). (See 'Lesion location' above.)
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REFERENCES
1. Fleischer AB Jr, Feldman SR, McConnell RC. The most common dermatologic problems identified by family
physicians, 1990-1994. Fam Med 1997; 29:648.
2. Garca-Hidalgo L, Orozco-Topete R, Gonzalez-Barranco J, et al. Dermatoses in 156 obese adults. Obes Res 1999;
7:299.
3. Romano G, Moretti G, Di Benedetto A, et al. Skin lesions in diabetes mellitus: prevalence and clinical correlations.
Diabetes Res Clin Pract 1998; 39:101.
4. Nahass GT, Meyer AJ, Campbell SF, Heaney RM. Prevalence of cutaneous findings in hospitalized medical patients. J
Am Acad Dermatol 1995; 33:207.
5. Krowchuk DP, Bradham DD, Fleischer AB Jr. Dermatologic services provided to children and adolescents by primary
care and other physicians in the United States. Pediatr Dermatol 1994; 11:199.
6. Ernst E. The usage of complementary therapies by dermatological patients: a systematic review. Br J Dermatol 2000;
142:857.
7. Gerbert B, Maurer T, Berger T, et al. Primary care physicians as gatekeepers in managed care. Primary care
physicians' and dermatologists' skills at secondary prevention of skin cancer. Arch Dermatol 1996; 132:1030.
8. Federman DG, Reid M, Feldman SR, et al. The primary care provider and the care of skin disease: the patient's
perspective. Arch Dermatol 2001; 137:25.
9. Gropper CA. An approach to clinical dermatologic diagnosis based on morphologic reaction patterns. Clin Cornerstone
2001; 4:1.
10. Federman DG, Kirsner RS. The patient with skin disease: an approach for nondermatologists. Ostomy Wound Manage
2002; 48:22.
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GRAPHICS
Common disorders encountered during the physical
examination of skin, front view
Reproduced with permission from Fitzpatrick, TB, Bernhard, JD, Copley, TG. In:
Dermatology in General Medicine, Freedberg, IN, Eisin, AZ, Wolff, K, et al. (Eds), 5th ed,
McGraw-Hill 1999. Copyright 1999 The McGraw-Hill Companies, Inc.
Graphic 61227 Version 1.0
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Common disorders encountered during the physical
examination of skin, back view
Reproduced with permission from Fitzpatrick, TB, Bernhard, JD, Copley, TG. In:
Dermatology in General Medicine, Freeberg, IN, Eisin, AZ, Wolff, K, et al. (Eds), 5th
ed, McGraw-Hill 1999. Copyright 1999 The McGraw-Hill Companies, Inc.
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Most frequent diagnoses seen by dermatologists and nondermatologists
Condition Percent
Dermatologists
Acne vulgaris 18
Dermatitis 13
Actinic keratosis 12
Skin cancer 7
Warts 7
Benign tumors 6
Psoriasis 5
Epidermoid cyst 3
Seborrheic keratosis 3
Tinea infections 2
Nondermatologists
Dermatitis 14
Pyoderma 11
Warts 6
Epidermoid cyst 5
Tinea infections 4
Candida 4
Acne vulgaris 3
Dermatosis NOS 3
Skin cancer 3
Benign tumors 3
Data from Fleisher, AB, Feldman, SR, McConnell, RC, Fam Med 1997; 29:648.
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Viral exanthem
Multiple erythematous macules are present on the skin of this patient
with a viral exanthem.
Reproduced with permission from: www.visualdx.com. Copyright Logical
Images, Inc.
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Solar lentigines presenting as brown macules on the
dorsum of the hand
Multiple brown macules are present on the dorsal hand.
Reproduced with permission from: www.visualdx.com. Copyright Logical
Images, Inc.
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Differential diagnosis of macules
Erythematous macules
Drug eruption
Viral exanthem
Secondary syphilis
Rheumatic fever
Photodistributed macules
Drugs
Dermatomyositis
Lupus erythematosus
Porphyria cutanea tarda
Polymorphous light eruption
Hypopigmented macules
Postinflammatory
Tinea versicolor
Vitiligo
Halo nevus
Sarcoidosis
Tuberous sclerosis
Cutaneous T cell lymphoma
Leprosy
Hyperpigmented macules
Nevi
Fixed drug eruption
Postinflammatory
Ephelis (freckle)
Lentigo
Schamberg's purpura
Nevus
Mongolian spot
Purpura
Stasis dermatitis
Melasma
Melanoma
Ochronosis
Mastocytosis
Caf au lait spot
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Dermatosis papulosa nigra
Multiple hyperpigmented papules are present on the face of this
patient with dermatosis papulosa nigra.
Reproduced with permission from: www.visualdx.com. Copyright Logical
Images, Inc.
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Differential diagnosis of papules
Isolated papules
Acrochordon
Actinic keratosis
Angiofibroma
Appendageal tumors (benign or malignant)
Bacillary angiomatosis
Basal cell carcinoma
Chondrodermatitis nodularis helicis
Dermatofibroma
Fungal infections (early)
Hemangioma
Keratoacanthoma
Melanoma
Milia
Molluscum contagiosum
Neurofibroma
Nevus
Pyogenic granuloma
Sebaceous hyperplasia
Seborrheic keratosis
Squamous cell carcinoma
Venous lake
Wart
Papular eruptions
Acne rosacea
Acne vulgaris
Appendageal tumors (usually benign)
Arthropod bite
Bacillary angiomatosis
Dermatomyositis
Drug eruption
Eczematous dermatitis
Flat warts
Folliculitis
Granuloma annulare
Keratosis pilaris
Lichen nitidus
Lichen planus
Lichen sclerosus
Lupus erythematosus
Lymphoma
Miliaria
Molluscum contagiosum
Neurofibromatosis
Pediculosis corporis
Perioral dermatitis
Pityriasis rosea
Polymorphous light eruption
Psoriasis
Sarcoidosis
Sarcoma
Scabies
Syphilis
Urticaria
Vasculitis
Viral exanthem
Xanthoma
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Plaque psoriasis
An erythematous plaque with coarse scale is present on the knee of
this patient with psoriasis.
Reproduced with permission from: www.visualdx.com. Copyright Logical
Images, Inc.
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Differential diagnosis of plaques
Acanthosis nigricans
Candidiasis
Cellulitis
Deep fungal infections
Dermatomyositis
Diaper dermatitis
Eczematous dermatitis
Erythrasma
Tinea infections
Granuloma annulare
Ichthyosis
Lichen planus
Lichen sclerosus
Lupus erythematosus
Lyme disease
Lymphoma (cutaneous T cell)
Morphea
Myxedema
Necrobiosis lipoidica diabeticorum
Paget's disease
Pityriasis rosea
Psoriasis
Sarcoidosis
Seborrheic dermatitis
Sweet's syndrome
Syphilis
Tinea versicolor
Vasculitis
Xanthelasma
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Multiple lipomas
Nodules are present on the arm of this patient with multiple lipomas.
Reproduced with permission from: www.visualdx.com. Copyright Logical
Images, Inc.
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Differential diagnosis of nodules and tumors
Acrochordon
Angioma
Appendageal tumors
Basal cell carcinoma
Callus/clavus
Chondrodermatitis nodularis helicis
Dermatofibroma
Dermatofibrosarcoma
Erythema nodosum
Hidradenitis suppurativa
Histiocytosis
Inclusion cyst
Kaposi's sarcoma
Keloid
Lipoma
Lymphoma (cutaneous)
Melanoma
Metastatic carcinoma
Neurofibroma
Nevus
Prurigo nodularis
Pyogenic granuloma
Seborrheic keratosis
Squamous cell carcinoma
Syphilis
Tuberous sclerosis
Venous lake
Wart
Xanthoma
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Pilar cyst
Reproduced with permission from: www.visualdx.com. Copyright Logical Images, Inc.
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Telangiectasias
Multiple telangiectasias are present on the nose.
Reproduced with permission from: www.visualdx.com. Copyright Logical
Images, Inc.
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Pustules in pustular psoriasis
Reproduced with permission from: www.visualdx.com. Copyright Logical
Images, Inc.
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Differential diagnosis of pustules
Acne rosacea/perioral dermatitis
Acne vulgaris
Arthropod bite (fire ants)
Drug eruption
Eosinophilic folliculitis
Erythema toxicum neonatorum
Folliculitis
Fungal or yeast infections (especially tinea capitis and Majocchi's granuloma)
Furunculosis
Gonorrhea (disseminated)
Herpes simplex/zoster
Impetigo
Keratosis pilaris
Neonatal pustulosis
Pseudofolliculitis barbae
Pustular psoriasis
Pyoderma gangrenosum
Syphilis
Varicella
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Vesicles
Multiple vesicles are present in this patient with herpes zoster.
Reproduced with permission from: www.visualdx.com. Copyright Logical
Images, Inc.
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Differential diagnosis of vesicles and bullae
Bullous disease in diabetes
Bullous pemphigoid
Burn
Cellulitis
Congenital syphilis
Contact dermatitis
Dermatitis herpetiformis
Eczema (especially hand/foot)
Epidermolysis bullosa
Erythema multiforme
Fixed drug eruption
Fungal infections (especially tinea pedis)
Hand foot and mouth disease
Herpes gestationis
Herpes simplex
Herpes zoster
Id reaction
Impetigo
Insect bite reaction
Lichen planus
Lupus erythematosus (bullous)
Pemphigus vulgaris/foliaceus
Porphyria cutanea tarda
Scabies
Staphylococcal scalded skin
Streptococcal toxic shock
Toxic epidermal necrolysis
Varicella
Vasculitis
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Urticaria
Skin-colored wheals are present.
Reproduced with permission from: Goodheart HP. Goodheart's Photoguide of
Common Skin Disorders, 2nd Edition. Philadelphia: Lippincott Williams &
Wilkins, 2003. Copyright 2003 Lippincott Williams & Wilkins.
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Excoriations
Linear excoriations (secondary to scratching) are present.
Reproduced with permission from: www.visualdx.com. Copyright Logical
Images, Inc.
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Lichenification
Thickened skin with accentuated skin lines are present in this patient
who chronically rubbed and scratched this area.
Reproduced with permission from: www.visualdx.com. Copyright Logical
Images, Inc.
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Angioedema of the lips
Reproduced with permission from: www.visualdx.com. Copyright Logical
Images, Inc.
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Scale
Actinic keratosis. Scale overlies erythematous macules.
Reproduced with permission from: www.visualdx.com. Copyright Logical
Images, Inc.
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Impetigo
Crusted lesions in a patient with impetigo.
Reproduced with permission from: www.visualdx.com. Copyright Logical Images, Inc.
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Inverse psoriasis
An erythematous, fissured plaque is present on the intergluteal skin.
Reproduced with permission from: Goodheart, HP. Goodheart's Photoguide of
Common Skin Disorders, 2nd ed, Lippincott Williams & Wilkins, Philadelphia
2003. Copyright 2003 Lippincott Williams & Wilkins.
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Erosions
Multiple shallow erosions are present in areas of sloughed skin in this
patient with toxic epidermal necrolysis.
Reproduced with permission from: www.visualdx.com. Copyright Logical
Images, Inc.
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Pyoderma gangrenosum
Peristomal pyoderma gangrenosum is caused by an inflammatory
process that produces severe and painful skin ulcerations; while these
lesions most commonly occur on the legs, they are also seen in the
peristomal area.
Courtesy of Dorothy B Doughty, MN, RN, CWOCN, FAAN.
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Differential diagnosis of erosions and ulcers
Mouth
Aphthae
Avitaminosis
Burn
Candidiasis
Epidermolysis bullosa
Erythema multiforme
Hand-foot-mouth disease
Herpangina
Herpes simplex
Lichen planus
Lupus erythematosus
Pemphigus vulgaris
Perlche
Toxic epidermal necrolysis
Genital
Balanitis
Candidiasis
Chancroid
Diaper dermatitis
Erythema multiforme
Fixed drug eruption
Fungal infections (tinea cruris)
Herpes simplex
Intertrigo
Lichen planus
Lichen sclerosus
Lymphogranuloma venereum
Squamous cell carcinoma
Syphilis
Other
Basal cell carcinoma
Bullous pemphigoid
Echthyma
Erythema multiforme
Ischemia
Necrobiosis lipoidica
Pemphigus vulgaris
Porphyria cutanea tarda
Pyoderma gangrenosum
Spider bite
Squamous cell carcinoma
Stasis ulcer
Toxic epidermal necrosis
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Extragenital lichen sclerosus
Multiple white, atrophic plaques are present on the chest.
Reproduced with permission from: www.visualdx.com. Copyright Logical Images, Inc.
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Dissecting cellulitis of the scalp
Extensive scarring in a patient with dissecting cellulitis of the scalp.
Reproduced with permission from: www.visualdx.com. Copyright Logical Images, Inc.
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Pityriasis alba
Hypopigmented macules are present on the face of this young girl
with pityriasis alba.
Copyright Nicole Sorensen, RN, Dermatlas; http://www.dermatlas.org.
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Postinflammatory hyperpigmentation
In this patient, healing acne was the cause of the postinflammatory
hyperpigmented patch.
Reproduced with permission from: Goodheart HP. Goodheart's Photoguide of
Common Skin Disorders, 2nd ed. Lippincott Williams & Wilkins, Philadelphia
2003. Copyright 2003 Lippincott Williams & Wilkins.
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Segmental vitiligo
Segmental vitiligo: patches of hypopigmentation on the anterior trunk.
Reproduced with permission from: Stedman's Medical Dictionary. Copyright
2008 Lippincott Williams & Wilkins.
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Distribution of common skin dermatoses
Flexural distribution
Acanthosis nigricans
Atopic dermatitis
Bullous pemphigoid
Extensor distribution
Psoriasis
Atopic dermatitis (infants)
Dermatitis herpetiformis
Xanthomas
Feet/hands
Eczema
Tinea infections and "id" reactions
Erythema multiforme
Wrists/ankles
Lichen planus
Scabies
Contact dermatitis
Eczema
Photodistributed
Lupus erythematosus
Photodrug eruption
Dermatomyositis
Pellagra
Porphyria cutanea tarda
Polymorphous light eruption
Mouth
Mucous cysts
Leukoplakia
Fordyce spots
Pyogenic granuloma
Skin cancers
Kaposi's sarcoma
Axillae
Acanthosis nigricans
Hidradenitis suppurativa
Impetigo
Hailey-Hailey disease
Achrocordon
Folliculitis
Erythrasma
Contact dermatitis
Buttocks/anal
Folliculitis
Psoriasis
Hidradenitis suppurativa
Lichen sclerosus et atrophicus
Streptococcal cellulitis
Kawasaki disease
Scalp
Seborrhea
Contact dermatitis
Tinea capitis and kerion
Discoid lupus
Psoriasis
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Di scl osures: Beth G Goldstein, MD Nothing to disclose. Adam O Goldstein, MD, MPH Nothing to disclose. Robert P Dellavalle, MD,
PhD, MSPH Nothing to disclose. Moise L Levy, MD Grant/Research/ Clinical Trial Support: GSK [psoriasis (calcipotriene)]; Anacor [atopic
dermatitis (investigational drug)]. Consultant/Advisory Boards: Galderma [acne (epiduo)]. Patent Holder: Incontinentia pigmenti (NEMO gene
mutations). Rosamaria Corona, MD, DSc Employee of UpToDate, Inc.
Contributor disclosures are reviewed f or conf licts of interest by the editorial group. When f ound, these are addressed by vetting through
a multi-level review process, and through requirements f or ref erences to be provided to support the content. Appropriately ref erenced
content is required of all authors and must conf orm to UpToDate standards of evidence.
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Disclosures
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