11/13/24, 7\:09 PM Guide | Rash & non-pigmented skin lesion exam

Rash & non-pigmented skin lesion exam

Table of contents

Introduction

Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Con
Brie
Explain the need for a chaperone if the skin lesion is located in an intimate area\:
p r e s e n t t h r o u g h o u t t h e e x a m i n a t i o n , a c t i n g a s a c h a p e r o n e , w o u l d t h a t b e o k ?”
Gain consent to proceed with the examination.
Adequately expose the skin lesion and position the patient so that you can clearly visualise it.
Ask the patient if they have any pain before proceeding with the clinical examination.
“ O n e o f t h e w a r d s t a

General inspection

Skin lesions

Note the number, location and distribution of the patient's skin lesions from the end of the bed\:
Acral distribution\: distal areas including the hands and feet (e.g. hand, foot and mouth disease).
Extensor distribution\: extensor surfaces including the elbows and knees (e.g. psoriasis).
Flexural distribution\:
Follicular distribution\: a
acne).
Dermatomal distribution\: the skin lesions appear con
herpes zoster).
Seborrhoeic distribution\: present in areas where there is an increased density of sebaceous glands such as the face and
scalp (e.g. seborrhoeic dermatitis).

Objects and equipment

Look for objects or equipment on or around the patient that may provide useful insights into their medical history and current
clinical status\:
Medical equipment\: may include bandages/dressings, oral medications and topical medications.
Mobility aids\: items such as wheelchairs and walking aids give an indication of the patient’s current mobility status.
Prescriptions\: prescribing charts or personal prescriptions can provide useful information about the patient’s recent
medications.
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Hand, foot and mouth disease [1]

Close inspection

Size of the lesion(s)

Assess the size of the lesion(s)\: measure their width and height (if raised).

Con

Assess the con
Con
can be useful in narrowing the di
When assessing con
Note if the lesion(s) is/are discrete or con
Note the shape of the lesion(s).
Assess the border of the lesion(s) (e.g. well/poorly de
Con
Discrete lesions\: individual lesions, clearly separated from one another (e.g. normal mole).
Con
Linear lesions\: lesions in the shape of a line (e.g. excoriations).
Discoid lesions\: coin-shaped lesions (e.g. discoid eczema, discoid lupus).
Target lesions\: concentric rings of varying colour, resembling a bullseye (e.g. erythema multiforme).
Annular lesions\: ring-like lesions (e.g. tinea corporis).
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Normal mole

Colour of the lesion(s)

Assess the colour of the lesion(s).
Colour examples
Erythematous lesions\: redness of the skin caused by an increased blood supply to the area. Erythematous lesions will
blanch when pressure is applied.
Purpuric lesions\: reddish/purple discolouration of the skin caused by small blood vessels bleeding into the skin. Purpuric
lesions do not blanch when pressure is applied. Petechiae are small purpuric lesions less than 2mm in diameter whereas
ecchymoses are larger purpura more than 2mm across (commonly referred to as a bruise).
Hyperpigmented lesions\: areas of darker skin caused by excess melanin production. Hyperpigmentation may be di
(e.g. Addison's disease) or discrete (linea nigra in pregnancy).
Hypopigmented skin lesions\: areas of paler skin caused by melanocyte and melanin depletion or dysfunction. Pityriasis
versicolour is a super
lesions.
Depigmentation\: areas of skin which appear completely white due to the absence of melanin. Vitiligo is an autoimmune
condition that results in the destruction of melanocytes and loss of pigment in the areas of skin a
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Petechiae [9]

Morphology of the lesion(s)

Assess the form and structure of the lesion(s)\: note if individual lesions appear
depressed below it.
Primary lesions
Primary skin lesions are those which develop as a direct result of a disease process.
Macule\: a
Patch\: a
Papule\: a solid raised palpable lesion less than 0.5cm in diameter.
Nodule\: a solid raised palpable lesion greater than 0.5cm in diameter.
Plaque\: a palpable
thickened without being visibly raised.
Vesicle\: a raised, clear
Bulla\: a raised, clear
Pustule\: a pus-containing lesion less than 0.5cm in diameter.
Abscess\: a localised accumulation of pus.
Wheal\: an oedematous papule or plaque caused by dermal oedema.
Boil/furuncle\: staphylococcal infection around or within a hair follicle.
Carbuncle\: staphylococcal infection of adjacent hair follicles (i.e. multiple boils/furuncles).
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Psoriasis [2]
Secondary lesions
Secondary lesions are modi
Excoriation\: loss of epidermis associated with trauma.
Licheni
scratching of an area (e.g. chronic eczema).
Scales\: visible fragments of the stratum corneum as it is shed from the skin, most commonly associated with psoriasis.
Crust\: a rough surface consisting of dried serum, blood, bacteria and cellular debris. The serum, blood, bacteria and
debris have usually exuded through an eroded epidermis.
Scar\: new
the scar resulting in a cratering e
wound boundary, resulting in a prominent scar. Keloidal scarring involves the hyperproliferation of scar tissue beyond the
wound boundary resulting in a scar that is signi
Ulcer\: a localised defect in the skin of irregular size and shape where the epidermis and some dermis have been lost.
Ulcers ultimately result in scarring when healed.
Fissure\: a sharply-de
dryness.
Striae (stretch marks)\: purple lines on the skin caused by tearing during the rapid growth or overstretching of skin (e.g.
growth spurts, ascites, intra-abdominal malignancy, Cushing’s syndrome, obesity, pregnancy). They undergo an evolution
of colour from purple to pink to white as they mature.
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Eczema
Assessment of a pigmented lesion
This guide does not cover the assessment of pigmented skin lesions, as they require a slightly di
including screening for features suggestive of malignant melanoma using the ABCDE criteria\:³
Asymmetry
Border irregularity
Colour variation or changes
Diameter
Elevation/evolution
For more information, see the Geeky Medics OSCE guide to examining a pigmented lesion.

Palpation

Don gloves if there is a risk that the skin lesion is infective and/or is likely to expose you to bodily
Assess the surface characteristics of the lesion\:
Texture\: note if the lesion feels smooth (e.g. ecchymoses) or rough (e.g. psoriatic plaque).
Elevation\: note if the lesion is
Crust\: if present, assess if you can remove the crust and inspect the underlying tissue (e.g. psoriasis).
Temperature\: assess the temperature of the lesions (e.g. an abscess may feel warm).
Assess the deeper characteristics of the lesion\:
Consistency\: note if the lesion feels hard,
Fluctuance\: hold the lesion by its sides and then apply pressure to the centre of the mass with another

Mobility\: assess if the lesion feels mobile or is tethered to other local structures.
Tenderness\: may indicate infective and/or in
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Systemic examination

Some skin conditions have extracutaneous manifestations whilst other skin lesions may develop secondary to a systemic
disease process. As a result, it's important to perform a comprehensive assessment to identify relevant pathology.

Hands and elbows

Inspect the nails and hands for relevant clinical signs.
Nail pitting\: punctate depressions of the nail plate associated with eczema, psoriasis and alopecia areata.
Onycholysis\: separation of the distal end of the nail plate from the nail bed associated with psoriasis and fungal nail infection.
Koilonychia\: spoon-shaped nails, associated with iron de
Elbows
arthritis).
Inspect the elbows for evidence of psoriasis plaques, xanthomas (hyperlipidaemia) or rheumatoid nodules (rheumatoid

Hair and scalp

Inspect the hair and scalp for relevant clinical signs.
Hair loss
Alopecia areata\: well-de
Alopecia totalis\: loss of all hair from the scalp.
Excess hair growth
Hirsutism\: androgen-dependent excess hair growth in females.
Hypertrichosis\: non-androgen-dependent excess hair growth.
Scalp
Scalp psoriasis\: plaques of psoriasis located on the scalp, often resulting in visible scale in the hair.
Seborrhoeic dermatitis\: often causes di

Mucous membranes

Inspect the oral mucosa for relevant clinical signs.
Hyperpigmented macules\: pathognomonic for Peutz-Jeghers syndrome, an autosomal dominant genetic disorder that results
in the development of polyps in the gastrointestinal tract.
Bullae\: associated with bullous pemphigoid, and pemphigus vulgaris, both autoimmune blistering disorders.
Whickham's striae\: a sign of lichen planus and can be in the buccal mucosa, but also on the genital skin.
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Nail pitting [23]

To complete the examination...

Explain to the patient that the examination is now
Thank the patient for their time.
Dispose of PPE appropriately and wash your hands.
Summarise your

Further assessments and investigations

Suggest further assessments and investigations to the examiner\:
Perform relevant examinations of any systems that may be related to dermatological
assessment).
Swabs/skin scrapings of lesions\: for microbiology, virology and fungal culture.
Dermatoscopy of lesions\: to more accurately assess a skin lesion (particularly melanocytic or vascular lesions).
Perform a biopsy of the skin lesion\: for histological analysis.
Source\: geekymedics.com
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