Far Eastern University NICANOR REYES MEDICAL FOUNDATION

Doctor of Medicine
2019
DERMATOLOGY: HISTORY & PHYSICAL EXAMINATION
Melissa P. Sandejas, MD
Medicine 3B
Drkhkh

HISTORY AND PHYSICAL EXAMINATION o (1) pinpoint to pinhead-sized bright

- The advantage in dermatology is that you
can see and feel what you need to examine
and a thorough physical examination is
paramount in diagnosing a disease
- Physical examination before history taking
PRIMARY LESIONS
- Most skin diseases produce or present with
lesions with more or less distinct
characteristic.
- The original lesions are known as primary
lesion.
- They are lesions not altered by trauma,
manipulation or natural regression over
time
red macules called petechiae
o (2) slightly bigger called purpura
o (3) very big and sometimes purplish
in color called echymosis.
- Green or blue seen commonly in newborn, was
used to be identified in Asians but
actually doesn’t have racial predilection,
called Mongolian spot
- Use the term morbilliform instead of
maculopapular

- Macule/ Patch
- Papule
- Plaque
- Nodule
- Tumor
- Wheal Café au lait Vitiligo
- Vesicle
- Bullae
- Pustule

MACULE / PATCH
- Discoloration of skin, flat < 1cm size
- Brown(epidermis), blue (dermis), red (RBCs,
blood vessels, inflammatory infiltrates
- Mainly a discoloration on the skin, of any
shape, flat.
- Brown discoloration is usually pigmentation
in the epidermis.
- Blue discoloration is usually pigmentation Purpura/Petechiae Morbiliform
in the dermis, Ecchymoses
- Red discoloration could be collection of
erythrocytes within blood vessels, or
inflammatory infiltrates (leukocytes)
within the immediate surrounding of blood
vessels.
- Clinical picture of patch stage of mycosis
fungoides.

Mongolian Spot

PAPULE
- Raised lesion, with no visible fluid less
than 1cm.
- Acuminate, rounded, conical, flat-topped,
umbilicated
- Clinical picture shows Lichen planus.
- Tan colored macules and patches called
café-au-lait (coffee and milk) macules seen
in neurofibromatosis.
- Vitiligo.
- Special macules:

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 Far Eastern University NICANOR REYES MEDICAL FOUNDATION
Doctor of Medicine
2019
DERMATOLOGY: HISTORY & PHYSICAL EXAMINATION
Melissa P. Sandejas, MD
Medicine 3B
Drkhkh

Lichen Planus Basal Cell Carcinoma

Molluscum contagiosum Melanocytic nevus Neurofibromas

TUMOR
- Soft or firm, freely movable or
fixedmasses, various shapes
- Generally > 2cm in diameter;their
consistency depends on the constituents of
the lesion
- Tumor is usually used to denote neoplasia

Xanthomas

PLAQUE
- Raised lesion, more than 1cm, usually flat-
topped but maybe centrally depressed
- Broad papule or confluence of papules WHEAL
- Basic descriptions
o erythematous and edematous papules
and plaques, evanescent
- Clinical picture
o a wheal is a prototypic lesion of
Urticaria

NODULE
- Important feature is that these lesions are
deep.
- The pathology is centered in dermis or
subcutaneous fat and are larger than 1 cm
- Clinical pictures (L-R): basal cell
carcinoma, neurofibromatosis

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 Far Eastern University NICANOR REYES MEDICAL FOUNDATION
Doctor of Medicine
2019
DERMATOLOGY: HISTORY & PHYSICAL EXAMINATION
Melissa P. Sandejas, MD
Medicine 3B
Drkhkh

VESICLE (Intraepidermal: Subcorneal) o Bullouspemphigoid (starts with

- Fluid-filled, less than 1cm they maybe pale wheal-like lesions, then develop
or yellow from serous exudate or red if blisters; seen more commonly in the
mixed with blood elderly)
- May be subclassified depending on where the
split occurs.
- Left picture shows the split occuring right
beneath the stratum corneum, naming this
subcornealintraepidermal vesicle.
- Clinical picture
o Impetigo

PUSTULE
- Pus-filled lesions usually of necrotic
inflam cells
- Doesn’t necessarily mean there is an
infectious process since there is such a
thing as a sterile pustule.

VESICLE (Intraepidermal)
- The split can occur mid-epidermis or right
over the basal layer.
- Clinical picture
o shingles; grouped vesicles

VESICLE (Subepidermal)
- The split can also occur right beneath the
epidermis.
- Clinical picture
o Pemphigusvulgaris
- Left clinical picture:
o lakes of pus, seen in psoriasis
(pustular type)
- Right clinical picture:
o Candidiasis

CYST
- Described as an encapsulated lesion, with
liquid or semi-solid contents.

BULLAE
- Fluid-filled, more than 1cm. They only
differ from the vesicle on in size
- The fluid content of a vesicle or a bullae
may be useful in cytologically confirming
the diagnosis of a skin disease
- Clinical picture:

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 Far Eastern University NICANOR REYES MEDICAL FOUNDATION
Doctor of Medicine
2019
DERMATOLOGY: HISTORY & PHYSICAL EXAMINATION
Melissa P. Sandejas, MD
Medicine 3B
Drkhkh

Milia Hidracystoma
- They vary in size, some are fine, delicate
and branny like in pityriasis or
tineaversicolor
- Others are coarser as in ichthyosis
- Some are stratified (“air-trapping”, giving
it a silvery color) as in psoriasis
- Large sheets of desquamated epidermis are
seen in TEN, SSSS

Epidermal cyst Milium

Tinea versicolor Ichthyosis

Steatocystoma multiplex

SECONDARY LESIONS
- Result of regression, trauma or other
extraneous factors towards your primary
lesions. For example the primary lesion in
sunburn is macular erythema but with
resolution secondary lesion will occur such
as scales and increased pigmentation
Psoriasis SSSS
- Scale
- Crust CRUST
- Fissure - Composed of keratin, dried serum,
- Erosion leukocytes, bacteria, debris.
- Ulcer - Dry golden yellow, soft, friable and
- Scar superficial as in impetigo

SCALE
- Dry or greasy laminated masses of keratin
- Our body normally sheds imperceptible
fragments of stratum corneum everyday.
When formation of epidermal cells is rapid,
or when there is disturbance in normal
keratinization, then we see pathologic
exfoliation, characterized by your scales.
- Clinical picture
o close up of seborrheic dermatitis

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 Far Eastern University NICANOR REYES MEDICAL FOUNDATION
Doctor of Medicine
2019
DERMATOLOGY: HISTORY & PHYSICAL EXAMINATION
Melissa P. Sandejas, MD
Medicine 3B
Drkhkh

FISSURE - Scars could be

- Linear cleft through the epidermis or into o Hypertrophic
the dermis o Keloidal
- They occur most when the skin is and o Atrophic
inelastic from inflammatin and dryness.
- This usually produces pain when the lesion
deepens or opens or form new ones
- Seen in chronic skin conditions such as:
Chronic allergic contact dermatitis
- Psoriasis

EROSION
- Loss of part of the epidermis.
- Important for the basal layer to be intact
since this is where new skin will arise.
No scarring Keloidal Atrophic

Hypertrophic Scar Keloid

ULCER
- Loss of all of the epidermis with or
without part of the dermis.
- Loss of the basal layer of the epidermis
means the connective tissue in the dermis
will try to fill up the defect, giving you
the scar.
- Hypertrophic scar (the scar doesn’t go
beyond the margins of the original wound;
there may be slight stretching of the skin,
expanding the wound)
- Keloid is overabundance of connective
tissue, seen in the ear-piercing of the
earlobe, which doesn’t produce a hole and
instead you have the protruding mass.

EXCORIATIONS AND ABRASIONS

- Punctate or linear lesions involving
epidermis sometimes reaching papillary
dermis.
- Usually caused by scratching with
fingernails in an effort to relieve itching
like in atopic dermatitis.
- If the skin damage is the result of
mechanical trauma or constant friction the
SCAR term abrasion may be used
- Scars are composed of new connective
tissues that replaced lost substance in the
dermis or deeper parts as a result of
injury or disease.

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 Far Eastern University NICANOR REYES MEDICAL FOUNDATION
Doctor of Medicine
2019
DERMATOLOGY: HISTORY & PHYSICAL EXAMINATION
Melissa P. Sandejas, MD
Medicine 3B
Drkhkh

- Fitzpatrick’s sign or dimple sign in

Dermatofibroma
o Pinching
o produces depression
- Auspitz sign in Psoriasis
o scraping/scratching
o presence of punctate bleeding when
scales are removed
- Nikolsky sign in Pemphigus
o lateral sliding pressure
o dislodgement of the superficial
epidermis by shearing force.
PHYSICAL EXAMINATION - Asboe-Hansen sign in Pemphigus
- Well-lit room (sunlight) o pressure over the blister
- Wood’s light (365nm)
- Magnifying lens DIAGNOSTIC DETAILS
- PALPATION, rubbing (Darier’s sign), - Distribution
scraping/ scratching (Auspitz sign), - Configuration
lateral pressure (Nikolsky sign),pressure - Grouping (DH, HS, HZ, SY)
on top of blister (Asboe-Hansen sign), - EVOLUTION and involution
pinching (Fitzpatrick’s sign) - Color
- Distribution - Consistency
- Grouping, Configuration - Hyperesthesia/Anesthesia
- Evolution, Involution
CONFIGURATION AND GROUPING

- Darier’s sign in Urticariapigmentosa

o Rubbing
o causing urtication and erythematous
halo when one rubs the lesion

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 Far Eastern University NICANOR REYES MEDICAL FOUNDATION
Doctor of Medicine
2019
DERMATOLOGY: HISTORY & PHYSICAL EXAMINATION
Melissa P. Sandejas, MD
Medicine 3B
Drkhkh

Herpes zoster

Pityriasisrosea Epidermal Nevi

(Christmas Tree Pattern) on Blaschko’s Lines

Polycyclic Varicella

When lesions disapper can have Ulcers, eschars

and scars of pityriasislichenoidesacuta

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