46 Approach to the Patient with a Skin Disorder 283

progestin such as norgestral, desonorgestrel, or norethisterone results

in effective contraception, suggesting that a male contraceptive may
be forthcoming.
FURTHER READING
ABMA JC et al and the National Center for Health Statistics: Fertility, family
planning, and womens health: New data from the 1995 Survey of Family
Growth. Vital Health Stat 23, no. 10
ANDERSON RA et al: Male contraception. Endocr Rev 23:735, 2002
GUZIK DS et al: Sperm morphology, motility and concentration in fertile and
infertile men. N Engl J Med 345:1388, 2001
KURODA-KAWAGUCHI T et al: The AZFc region of the Y chromosome fea-
tures massive palindromes and uniform recurrent deletions in infertile men.
Nat Genet 29:279, 2001
MARCHBANKS PA et al. Oral contraceptives and the risk of breast cancer. N
Engl J Med 346:2025, 2002
TRUSSELL J, VAUGHAN B: Contraceptive failure, method-related discontinu-
ation and resumption of use: Results from the 1995 National Survey of
Family Growth. Fam Plan Perspect 31:64, 1999
Section 9 Alterations in the Skin
46
APPROACH TO THE PATIENT WITH A SKIN DISORDER
Thomas J. Lawley, Kim B. Yancey
FIGURE 46-2 Nevi are benign proliferations of nevomelanocytes characterized by
regularly shaped hyperpigmented macules or papules of a uniform color.
FIGURE 46-1 Superficial spreading melanoma is the most common type of malignant
melanoma and demonstrates color variegation (black, blue, brown, pink, and white)
and irregular borders.
TABLE 46-1 Descriptions of Primary Skin Lesions
Macule: A at, colored lesion, 2 cm in diameter, not raised above the
surface of the surrounding skin. A freckle, or ephelid, is a prototype
pigmented macule.
Patch: A large (2 cm), at lesion with a color different from the surround-
ing skin. This differs from a macule only in size.
Papule: A small, solid lesion, 0.5 cm in diameter, raised above the surface
of the surrounding skin and hence palpable (e.g., a closed comedone, or
whitehead, in acne).
Nodule: A larger (0.55.0 cm), rm lesion raised above the surface of the
surrounding skin. This differs from a papule only in size (e.g., dermal
nevus).
Tumor: A solid, raised growth 5 cm in diameter.
Plaque: A large (1 cm), at-topped, raised lesion; edges may either be
distinct (e.g., in psoriasis) or gradually blend with surrounding skin (e.g.,
in eczematous dermatitis).
Vesicle: A small, uid-lled lesion, 0.5 cm in diameter, raised above the
plane of surrounding skin. Fluid is often visible, and the lesions are often
translucent [e.g., vesicles in allergic contact dermatitis caused by Toxi-
codendron (poison ivy)].
Pustule: A vesicle lled with leukocytes. Note: The presence of pustules
does not necessarily signify the existence of an infection.
Bulla: A uid-lled, raised, often translucent lesion 0.5 cm in diameter.
Cyst: A soft, raised, encapsulated lesion lled with semisolid or liquid
contents.
Wheal: A raised, erythematous papule or plaque, usually representing short-
lived dermal edema.
Telangiectasia: Dilated, supercial blood vessels.
The challenge of examining the skin lies in distinguishing normal from
abnormal, signicant ndings from trivial ones, and in integrating per-
tinent signs and symptoms into an appropriate differential diagnosis.
The fact that the largest organ in the body is visible is both an advan-
tage and a disadvantage to those who examine it. It is advantageous
because no special instrumentation is necessary and because the skin
can be biopsied with little morbidity. However, the casual observer
can be misled by a variety of stimuli and overlook important, subtle
signs of skin or systemic disease. For instance, the sometimes minor
differences in color and shape that distinguish a malignant melanoma
(Fig. 46-1) from a benign pigmented nevus (Fig. 46-2) can be difcult
to recognize. To aid in the interpretation of skin lesions, a variety of
descriptive terms have been developed to characterize cutaneous le-
sions (Tables 46-1 and 46-2 and Fig. 46-3) and to formulate a differ-
ential diagnosis (Table 46-3). For instance, the nding of large num-
bers of scaling papules, usually indicative of a primary skin disease,
places the patient in a different diagnostic category than would hem-
orrhagic papules, which may indicate vasculitis or sepsis (Figs. 46-4
and 46-5, respectively). It is important to differentiate primary skin
lesions from secondary skin changes. If the examiner focuses on linear
erosions overlying an area of erythema and scaling, he or she may
incorrectly assume that the erosion is the primary lesion and the red-
ness and scale are secondary, while the correct interpretation would
be that the patient has a pruritic eczematous dermatitis with erosions
caused by scratching.
APPROACH TO THE PATIENT
In examining the skin it is usually advisable to assess the patient
before taking an extensive history. This way, the entire cutaneous
surface is sure to be evaluated, and objective ndings can be in-
tegrated with relevant historic data. Four basic features of any cu-
taneous lesion must be noted and considered in the examination of
Part II Cardinal Manifestations and Presentation of Diseases 284
TABLE 46-2 Common Dermatologic Terms
Lichenication: A distinctive thickening of the skin that is characterized
by accentuated skin-fold markings and that feels thick on palpation.
Crust: Dried exudate of body uids that may be either yellow (serous ex-
udate) or red (hemorrhagic exudate).
Milia: Small, rm, white papules that are lled with keratin (and may in
part resemble pustules).
Erosion: Loss of epidermis without an associated loss of dermis.
Ulcer: Loss of epidermis and at least a portion of the underlying dermis.
Excoriations: Linear, angular erosions that may be covered by crust and
are caused by scratching.
Atrophy: An acquired loss of substance. In the skin, this may appear as a
depression with intact epidermis (i.e., loss of dermal or subcutaneous
tissue) or as sites of shiny, delicate, wrinkled lesions (i.e., epidermal
atrophy).
Scar: A change in the skin secondary to trauma or inammation. Sites may
be erythematous, hypopigmented, or hypertrophic depending on their age
or character. Sites on hair-bearing areas may be characterized by destruc-
tion of hair follicles.
Pruritus: A sensation that elicits the desire to scratch. Pruritus is often the
predominant symptom of inammatory skin diseases (e.g., atopic der-
matitis, allergic contact dermatitis); it is also commonly associated with
xerosis and aged skin. Systemic conditions that can be associated with
pruritus include chronic renal disease, cholestasis, pregnancy, malig-
nancy, polycythemia vera, and delusions of parasitosis.
FIGURE 46-4 Palpable purpuric papules on
the lower legs are seen in this patient with
cutaneous small vessel vasculitis. (Courtesy of
Robert Swerlick, MD.)
b a c
Red
b
Blue
a
Brown
M
a
c
u
l
e
P
a
p
u
l
e
N
o
d
u
l
e
P
l
a
q
u
e
V
e
s
i
c
l
e
B
u
l
l
a
FIGURE 46-3 A schematic representation of several common primary skin lesions
(see Table 46-1).
FIGURE 46-5 Fulminant meningococcemia with extensive angular purpuric patches.
(Courtesy of Stephen E. Gellis, MD.)
skin: the distribution of the eruption, the type(s) of primary lesion,
the shape of individual lesions, and the arrangement of the lesions.
In the initial examination it is important that the patient be disrobed
as completely as possible. This will minimize chances of missing
important individual skin lesions and make it possible to assess the
distribution of the eruption accurately. The patient should rst be
viewed from a distance of about 1.5 to 2 m (4 to 6 ft) so that the
general character of the skin and the distribution of lesions can be
evaluated. Indeed, distribution of lesions often correlates highly
with diagnosis (Fig. 46-6). For example, a hospitalized patient with
a generalized erythematous exanthem is more likely to have a drug
eruption than is a patient with a similar rash limited to the sun-
exposed portions of the face. The presence or absence of lesions
on mucosal surfaces should also be determined. Once the distri-
bution of the lesions has been established, the nature of the primary
lesion must be determined. Thus, when lesions are distributed on
elbows, knees, and scalp, the most likely possibility based solely
on distribution is psoriasis or dermatitis herpetiformis (Figs. 46-7
and 46-8, respectively). The primary lesion in psoriasis is a scaly
papule that soon forms erythematous plaques covered with a white
scale, whereas that of dermatitis herpetiformis is an urticarial pap-
ule that quickly becomes a small vesicle. In this manner, identi-
cation of the primary lesion directs the examiner toward the proper
diagnosis. Secondary changes in skin can also be quite helpful. For
example, scale represents excessive epidermis, while crust is the
result of a discontinuous epithelial cell layer. Palpation of skin
lesions can also yield insight into the character of an eruption. Thus
red papules on the lower extremities that blanch with pressure can
be a manifestation of many different diseases, but hemorrhagic red
papules that do not blanch with pressure indicate palpable purpura
characteristic of necrotizing vasculitis (Fig. 46-4).
The shape of lesions is also an important feature. Flat, round,
erythematous papules and plaques are common in many cutaneous
diseases. However, target-shaped lesions that consist in part of er-
ythematous plaques are specic for erythema multiforme (Fig. 46-
9). In the same way, the arrangement of individual lesions is im-
portant. Erythematous papules and vesicles can occur in many
conditions, but their arrangement in a specic linear array suggests
an external etiology such as allergic contact (Fig. 46-10) or primary
TABLE 46-3 Selected Common Dermatologic Conditions
Diagnosis
Common
Distribution Usual Morphology
Acne vulgaris Face, upper back Open and closed comedones,
erythematous papules,
pustules, cysts
Rosacea Blush area of
cheeks, nose,
forehead, chin
Erythema, telangiectasias,
papules, pustules
Seborrheic
dermatitis
Scalp, eyebrows,
perinasal areas
Erythema with greasy yellow-
brown scale
Atopic dermatitis Antecubital and
popliteal fossae;
may be
widespread
Patches and plaques of
erythema, scaling, and
lichenication; pruritus
Stasis dermatitis Ankles, lower legs Patches of erythema and
scaling on background of
hyperpigmentation
associated with signs of
venous insufciency
Dyshidrotic
eczema
Palms, soles, sides
of ngers and toes
Deep vesicles
Allergic contact
dermatitis
Anywhere Localized erythema, vesicles,
scale, and pruritus (e.g.,
ngers, earlobesnickel;
dorsal aspect of foot
shoe; exposed surfaces
poison ivy)
Psoriasis Elbows, knees,
scalp, lower back,
ngernails (may
be generalized)
Papules and plaques covered
with silvery scale; nails
have pits
Lichen planus Wrists, ankles,
mouth (may be
widespread)
Violaceous at-topped
papules and plaques
Keratosis pilaris Extensor surfaces of
arms and thighs,
buttocks
Keratotic follicular papules
with surrounding erythema
Melasma Forehead, cheeks,
temples, upper lip
Tan to brown patches
Vitiligo Perioricial, trunk,
extensor surfaces
of extremities,
exor wrists,
axillae
Chalk-white macules
Actinic keratosis Sun-exposed areas Skin-colored or red-brown
macule or papule with dry,
rough, adherent scale
Basal cell
carcinoma
Face Papule with pearly,
telangiectatic border on
sun-damaged skin
Squamous cell
carcinoma
Face, especially
lower lip, ears
Indurated and possibly
hyperkeratotic lesions often
showing ulceration and/or
crusting
Diagnosis
Common
Distribution Usual Morphology
Seborrheic
keratosis
Trunk, face Brown plaques with adherent,
greasy scale; stuck on
appearance
Folliculitis Any hair-bearing
area
Follicular pustules
Impetigo Anywhere Papules, vesicles, pustules,
often with honey-colored
crusts
Herpes simplex Lips, genitalia Grouped vesicles progressing
to crusted erosions
Herpes zoster Dermatomal, usually
trunk but may be
anywhere
Vesicles limited to a
dermatome (often painful)
Varicella Face, trunk, relative
sparing of
extremities
Lesions arise in crops and
quickly progress from
erythematous macules to
papules to vesicles to
pustules to crusts
Pityriasis rosea Trunk (Christmas
tree pattern);
herald patch
followed by
multiple smaller
lesions
Symmetric erythematous
patches with a collarette of
scale
Tinea versicolor Chest, back,
abdomen,
proximal
extremities
Scaly hyper- or
hypopigmented macules
Candidiasis Groin, beneath
breasts, vagina,
oral cavity
Erythematous macerated
areas with satellite pustules;
white, friable patches on
mucous membranes
Dermatophytosis Feet, groin, beard,
or scalp
Varies with site, (e.g., tinea
corporisscaly annular
patch)
Scabies Groin, axillae,
between ngers
and toes, beneath
breasts
Excoriated papules, burrows,
pruritus
Insect bites Anywhere Erythematous papules with
central puncta
Cherry angioma Trunk Red, blood-lled papules
Keloid Anywhere (site of
previous injury)
Firm tumor, pink, purple, or
brown
Dermatobroma Anywhere Firm red to brown nodule that
shows dimpling of
overlying skin with lateral
compression
Acrochordons
(skin tags)
Groin, axilla, neck Fleshy papules
Urticaria Anywhere Wheals, sometimes with
surrounding are; pruritus
Transient acantho-
lytic dermatosis
Trunk, especially
anterior chest
Erythematous papules
Xerosis Extensor
extremities,
especially legs
Dry, erythematous, scaling
patches; pruritus
irritant dermatitis. In contrast, lesions with a generalized arrange-
ment are common and suggest a systemic etiology.
As in other branches of medicine, a complete history should be
obtained to emphasize the following features:
1. Evolution of lesions
a. Site of onset
b. Manner in which the eruption progressed or spread
c. Duration
d. Periods of resolution or improvement in chronic eruptions
2. Symptoms associated with the eruption
a. Itching, burning, pain, numbness
b. What, if anything, has relieved symptoms
c. Time of day when symptoms are most severe
3. Current or recent medications (prescribed as well as over-the-
counter)
4. Associated systemic symptoms (e.g., malaise, fever, arthral-
gias)
5. Ongoing or previous illnesses
6. History of allergies
7. Presence of photosensitivity
8. Review of systems
DIAGNOSTIC TECHNIQUES Many skin diseases can be diagnosed on gross
clinical appearance, but sometimes relatively simple diagnostic pro-
cedures can yield valuable information. In most instances, they can be
performed at the bedside with a minimum of equipment.
Actinic
keratoses
Basal cell
carcinoma
Contact
dermatitis
Skin tags
Acne vulgaris
Perleche
Seborrheic
dermatitis
Acne rosacea
Xanthelasma
Seborrheic
dermatitis
Melasma
Seborrheic
dermatitis
C
Herpes labialis
Leukoplakia
Squamous cell
carcinoma
Oral hairy
leukoplakia
Aphthous
stomatitis
Geographic
tongue
Lichen planus
D
Psoriasis
Acne
vulgaris
Pityriasis
rosea
Lichen
planus
Perianal lesions
Hemorrhoids
Condyloma
acuminata
Herpes simplex
Dermatitis
Vitiligo
Atopic
dermatitis
Hand eczema
Verruca plana
Tinea pedis
Lichen simplex
chronicus
Asteatotic
eczema
Verrucae vulgaris
Keratosis
pilaris
Skin tags
Seborrheic
keratoses
Senile
angioma
Atopic
dermatitis
Tinea or
Candida
cruris
Actinic
keratoses
Psoriasis
Dermatofibroma
Stasis ulcer
Stasis dermatitis
Tinea pedis
Dyshidrotic
eczema
Epidermal
inclusion
cyst
Herpes
zoster
Psoriasis
Psoriasis
Folliculitis
A B
FIGURE 46-6 AD. The distribution of some common dermatologic diseases and lesions.
FIGURE 46-7 Psoriasis is characterized by small and large erythematous plaques with
adherent silvery scale.
Skin Biopsy A skin biopsy is a straightforward minor surgical proce-
dure; however, it is important to biopsy a lesion that is most likely to
yield diagnostic ndings. This decision may require expertise in skin
diseases and knowledge of supercial anatomic structures in selected
areas of the body. In this procedure, a small area of skin is anesthetized
with 1% lidocaine with or without epinephrine. The skin lesion in
question can be excised with a scalpel or removed by punch biopsy.
In the latter technique, a punch is pressed against the surface of the
skin and rotated with downward pressure until it penetrates to the
subcutaneous tissue. The circular biopsy is then lifted with forceps,
and the bottom is cut with iris scissors. Biopsy sites may or may not
need suture closure, depending on size and location.
KOH Preparation A potassium hydroxide (KOH) preparation is per-
formed on scaling skin lesions where a fungal etiology is a possibility.
The edge of such a lesion is scraped gently with a scalpel blade, and
the removed scale is collected on a glass microscope slide and treated
with 1 to 2 drops of a solution of 10 to 20% KOH. KOH dissolves
keratin and allows easier visualization of fungal elements. Brief heat-
ing of the slide accelerates dissolution of keratin. When the preparation
46 Approach to the Patient with a Skin Disorder 287
FIGURE 46-8 Dermatitis herpetiformis manifested by pruritic, grouped vesicles in a
typical location. The vesicles are often excoriated and may occur on knees, buttocks,
and posterior scalp.
A
B
FIGURE 46-10 A. Allergic contact dermatitis, acute phase, with sharply demar-
cated, weeping, eczematous plaques in a perioral distribution. B. Allergic contact
dermatitis to nickel, chronic phase demonstrating an erythematous, lichenified, weep-
ing plaque on skin chronically exposed to a metal snap. (B, Courtesy of Robert
Swerlick, MD.)
FIGURE 46-9 Erythema multiforme is characterized by multiple erythematous plaques
with a target or iris morphology and usually represents a hypersensitivity reaction to
drugs or infections (especially herpes simplex virus). (Courtesy of the Yale Residents
Slide Collection.)
FIGURE 46-11 Urticaria showing characteristic discrete and confluent, edematous,
erythematous papules and plaques.
is viewed under the microscope, the refractile hyphae will be seen
more easily when the light intensity is reduced and the condenser is
lowered. This technique can be utilized to identify hyphae in dermat-
ophyte infections (see Fig. 190-1), pseudohyphae and budding yeast
in Candida infections (see Fig. 187-1), and fragmented hyphae and
spores in tinea versicolor. The same sampling technique can be used
to obtain scale for culture of selected pathogenic organisms.
Tzanck Smear A Tzanck smear is a cytologic technique most often used
in the diagnosis of herpesvirus infections [simplex or varicella-zoster
(see Figs. 164-1 and 164-3). An early vesicle, not a pustule or crusted
lesion, is unroofed, and the base of the lesion is scraped gently with a
scalpel blade. The material is placed on a glass slide, air-dried, and
stained with Giemsa or Wrights stain. Multinucleated epithelial giant
cells suggest the presence of herpes, but culture or immunouores-
cence testing must be performed to identify the specic virus.
Diascopy Diascopy is designed to assess whether a skin lesion will
blanch with pressure as, for example, in determining whether a red
lesion is hemorrhagic or simply blood-lled. For instance, urticaria
(Fig. 46-11) will blanch with pressure, whereas a purpuric lesion
caused by necrotizing vasculitis (Fig. 46-4) will not. Diascopy is per-
formed by pressing a microscope slide or magnifying lens against a
lesion and noting the amount of blanching that occurs. Granulomas
often have an apple jelly appearance on diascopy.
Woods Light A Woods lamp generates 360-nm ultraviolet (or
black) light that can be used to aid the evaluation of certain skin
disorders. For example, a Woods lamp will cause erythrasma (a su-
percial, intertriginous infection caused by Corynebacterium minutis-
simum) to show a characteristic coral red color, and wounds colonized
by Pseudomonas to appear pale blue. Tinea capitis caused by certain
dermatophytes such as Microsporum canis or M. audouini exhibits a
yellow uorescence. Pigmented lesions of the epidermis such as freck-
les are accentuated, while dermal pigment such as postinammatory
hyperpigmentation fades under a Woods light. Vitiligo (Fig. 46-12)
Part II Cardinal Manifestations and Presentation of Diseases 288
FIGURE 46-12 Vitiligo in a typical acral distribution demonstrating striking cutaneous
depigmentation, as a result of loss of melanocytes.
appears totally white under a Woods lamp, and previously unsus-
pected areas of involvement often become apparent. A Woods lamp
may also aid in the demonstration of tinea versicolor and in recognition
of ash leaf spots in patients with tuberous sclerosis.
Patch Tests Patch testing is designed to document sensitivity to a spe-
cic antigen. In this procedure, a battery of suspected allergens is
applied to the patients back under occlusive dressings and allowed to
remain in contact with the skin for 48 h. The dressings are removed,
and the area is examined for evidence of delayed hypersensitivity re-
actions (e.g., erythema, edema, or papulovesicles). This test is best
performed by physicians with special expertise in patch testing and is
often helpful in the evaluation of patients with chronic dermatitis.
FURTHER READING
ARNDT KA et al (eds): Cutaneous Medicine and Surgery, An Integrated Pro-
gram in Dermatology. Philadelphia, Saunders, 1996
CHAMPION RH et al (eds): Textbook of Dermatology, 6th ed. Oxford, Black-
well Scientic, 1999
DERMATOLOGY LEXICON PROJECT: www.dermatology lexicon.org
FREEDBERG IM et al (eds): Fitzpatricks Dermatology in General Medicine,
5th ed. New York, McGraw-Hill, 1999
47
ECZEMA, PSORIASIS, CUTANEOUS INFECTIONS, ACNE, AND OTHER
COMMON SKIN DISORDERS
Calvin O. McCall, Thomas J. Lawley
TABLE 47-1 Clinical Features of Atopic Dermatitis
1. Pruritus and scratching
2. Course marked by exacerbations and remissions
3. Lesions typical of eczematous dermatitis
4. Personal or family history of atopy (asthma, allergic rhinitis, food
allergies, or eczema)
5. Clinical course lasting longer than 6 weeks
FIGURE 47-1 Atopic dermatitis with hyperpigmentation, lichenification, and scaling
in the antecubital fossae. (Courtesy of Robert Swerlick, MD.)
ECZEMA AND DERMATITIS
Eczema, or dermatitis, is a reaction pattern that presents with variable
clinical and histologic ndings and is the nal common expression for
a number of disorders, including atopic dermatitis, allergic contact and
irritant contact dermatitis, dyshidrotic eczema, nummular eczema, li-
chen simplex chronicus, asteatotic eczema, and seborrheic dermatitis.
Primary lesions may include papules, erythematous macules, and ves-
icles, which can coalesce to form patches and plaques. In severe ec-
zema, secondary lesions from infection or excoriation, marked by
weeping and crusting, may predominate. Long-standing dermatitis is
often dry and is characterized by thickened, scaling skin (lichenica-
tion).
ATOPIC DERMATITIS Atopic dermatitis (AD) is the cutaneous expression
of the atopic state, characterized by a family history of asthma, hay
fever, or dermatitis in up to 70% of patients. Some of the features of
atopic eczema are shown in Table 47-1. The prevalence of atopic der-
matitis is increasing worldwide, with a point prevalence in Norwegian
school children as high as 23%.
The etiology of AD is only partially dened, but there is a clear
genetic predisposition. When both parents are affected by AD, over
80% of their children manifest the disease. When only one parent is
affected, the prevalence drops to slightly over 50%. Patients with AD
may display a variety of immunoregulatory abnormalities including
increased IgE synthesis; increased serum IgE; increased specic IgE
to foods, aeroallergens, bacteria, and bacterial products; increased ex-
pression of CD23 (low-afnity IgE receptor) on monocytes and B
cells; and impaired delayed type hypersensitivity reactions.
The clinical presentation often varies with age. Half of patients with
AD present within the rst year of life, and 80% present by 5 years of
age. About 80% ultimately coexpress allergic rhinitis or asthma. The
infantile pattern is characterized by weeping inammatory patches and
crusted plaques that occur on the face, neck, and extensor surfaces. The
childhood and adolescent pattern is marked by dermatitis of exural
skin, particularly in the antecubital and popliteal fossae (Fig. 47-1). AD
may resolve spontaneously, but over half of all individuals affected as
children will have dermatitis in adult life. The distribution of lesions
may be similar to those seen in childhood. However, adults frequently
have localized disease, manifesting as hand eczema or lichen simplex
chronicus (see below). In patients with localized disease, AD may be
suspected because of a typical personal history, family history, or the
presence of cutaneous stigmata of AD such as perioral pallor, an extra
fold of skin beneath the lower eyelid (Dennies line), increased palmar
skin markings, and an increased incidence of cutaneous infections, par-
ticularly with Staphylococcus aureus. Regardless of other manifesta-
tions, pruritus is a prominent characteristic of AD and is exacerbated by
dry skin. Many of the cutaneous ndings in affected patients, such as
lichenication, are secondary to rubbing and scratching.