DERMATOLOGY EXAM

John Zic, MD Michael L. Smith, MD

 DERMATOLOGY FOR THE PRIMARY HEALTH CARE PROVIDER

John A. Zic, M.D. I. PHYSICAL

ASSESSMENT OF THE SKIN

Definition of Terms
Secondary Lesions
SKIN LESIONS A primary lesion that has
changed due to the natural
progression of • the lesion or
Primary Lesions - A visually recognizable due to physical change, i.e.
structural change in the skin that scratching, irritation, or
has specific characteristics and secondary infection.
may arise in normal skin.
Plaque •' Araised flat lesion
Maculae - A change in .skin color, vithout formed froma
elevation that Is flat and flush vith confluence of papules or
the surrounding skin. The lesion is nodules.
described as a 'patch' if greater
than 1 cm. Scale Dried fragments of
sloughed dead epidermal
Papule - An elevated solid lesion less cells, irregular in shape
than 1 cm. varying in color. and size: White, tan,
yellov, or silver in
Module - Larger than a papule. A raised color.
'solid lesion that extends deeper into
the dermis. Crust Dried serum, sebum,
blood, or pus chat forns
Tumor - Amass larger than a nodule. on the surface of the skin
An elevated firm lesion that Bay or producing a temporary
nay not bt easily demarcated. barrier to the
environment. .
Vheal - A- raised fleeting elevation in
the skin, irregularly shaped due to A moist, demarcated
the presence of edema. Erosion depressed area due to
loss of partial or full
Vesicle - An elevated, sharply defined thickness of the epidermis.
lesion containing serous fluid, The basal layer of the
usually less than 1 cm. epidermis remains intact.
Bulla - A large elevated fluid-filled An irregularly-shaped
lesion greater than 1 CD (plural: Ulcer exudative de pressed lesion
bullae). in which the entire epidermis
and upper layer of the dermis
Cyst - An elevated thick-vailed is lost. Results from trauma
lesion containing fluid or semisolid and tissue destruction.
natter.
Scar A mark on tht akin after
Pustule - An elevated lesion, less than 1 healing. Replacement of
en. containing purulent material. diitroycd tiaiues by
Lesions larger than 1 CD are flbroui tiasu*.
described as bo.il*, abcesses, or Lichenification Epidermal
furuncles. thickening resulting in an
elevated plaque vith
accentuated skin markings. Usually a result of
repeated injury through rubbing or Itching.
Excoriation Superficial linear abrasion of the
epidermis. A visable sign of itching.
Fissure A deep linear split through the
epidermis into the dermis, a linear ulcer.
 I. PHYSICAL ASSESSMENTOF THE SKIN

L a b e lin g o f S k in L e sio n s, b y C o n fig u ra tio n a n d D istrib u tio n

C o n fig u ra tio n ;- T h e a rra n g e m e n t o r p a tte rn o f le sio n s in re la tio n to
o th e r le sio n A trophy - W astin g o f th e ep id erm is in w.hskin
ich th
appears
e
thin and transparentin orthe derm is in w hich a
Annular - Ring-shaped focal area of depression is observed.
Irii L e sio n s - C o n c e n tric rin g s; " B u lls e y e s" S triae - D ep ressed ban d s o f th in w h ite
skin.sh in y
G y ra te - R in g -sp ira l sh a p e X eloid - A benign overgrow th of connective
tissue follow ing a skin injury; a
L in e a r - In a lin e hyp«rtrophic scar.
N im m u l.tr, D isco-id C o in-lik e T elangieetasl*- Perm anent dilitation o f capillary
sels in
vesthe skin.
A ppears as
f i n e ,bright red branching lines.
P o ly m o rp h o u s - O c c u rrin g In se v e ra l fo n ts
P u n c ta te - H a rk e d b y p o in ts o r d o ts
S e rp ig in o u s - S n a k e -lik e
- T h e a rra n g e m e n t o f le sio n s o v e r a n a re a o f
D istrib u tio n ! sk in
C o llection of ex trav ascular b lood in derm is or
- A sin g le le sio n V asc u lar L e sio n s subcu tan eou s tissu e, caused
by traum a and
S o lita ry resulting in a m acular
lesion.
•
S a te llite - S in g le le sio n in c lo se p ro x im ity to a laErge ce h y a o s(B
is ru ise ) - C h erry -red, raised papu les distributed
over the
g ro u p in g crunk and extrem ities.
- C lu ste r o f le sio n s L o calized , deep co llection ofbeneath
b lo od the
- M e rg in g to g e th e r subcutaneous tissu e.
C h e rry A n g io m a
- W id e ly d istrib u te d P urplish hem orrhagic s p o ts pinpoint
, In size.
- S e p a ra te fro n o th e r le sio n s Hematona Irreg ular, larg e m acular area v aried
w ith
c o lo r: d ark p u rp le-red
brow to nish-yellow .
G e n eralize d - D istrib u te d d iffu se ly P e tec h ia e
L o c a liz e d - L im ite d a re a s o f in v o lv e m e n t w h ic h a re
S y m m e tricoarl d e fin e d c le a rly
'A ssym etrical
- D istrib u te d b ila te ra lly o r u n ila te ra lly
Z o ste rlfo rm
B a n d -lik e d istrib u tio n a lo n g a
d e rm a to o e a re a
 DERMATOLOGIC PROCEDURES IN YOUR OFFICE
Michael L. Smith, M. D.

Diagnosis of skin disease can be a challenging and rewarding task. Visual clues
combined with knowledge of basic pathologic processes in the skin are often all that one
needs to establish a correct diagnosis. However, a number of skin changes can represent
broad differential diagnostic categories, often requiring diagnostic procedures for proper
delineation. Most of these procedures can be performed quickly and easily in the office,
providing a much more complete diagnostic armamentarium. The following list of
procedures is intended as a rough guide, with current CLIA regulations included where
appropriate.

I. OSHA and the office laboratory

• Occupational safety in the office lab is a fundamental requirement.

Hazardous chemical storage and hazardous waste disposal must comply
with current OSHA rules. Universal precautions should be used to avoid
skin contact with potentially infectious materials. Any health care institution
which performs invasive procedures must have a written exposure control
plan by July 1, 1993, and a designated infection control staff member by
January 1, 1994.

• For complete guidelines, use Federal Register excerpt in Appendix, followed

by N.C. General Statues 130A-144 and 130A-145.

II. CLIA and the office laboratory

• The Clinical Laboratory Improvement Act of 1988 requires

certification and routine inspection of non-exempt office labs, with
certification fees ranging up to $3,000. Stiff penalties may be imposed if
non-exempt procedures are performed (and billed) in non-certified labs.

• Exempt ("waivered") procedures to date include:

Dipstick or tablet reagent urinalysis for:
bilirubin, glucose, hemoglobin, ketone, leukocytes, nitrite, pH,
protein, urobilinogen, specific gravity
Ovulation tests — visual color tests for human luteinizing
hormone
Urine pregnancy tests — visual color comparison
Erythrocyte sedimentation rate (non-automated)
Hemoglobin (by copper sulfate)
Fecal occult blood
Spun microhematocrit
Blood glucose (FDA-cleared home-use devices).
 • New regulations issued on January 19, 1993 established a new category
of waivered tests which physicians may perform without complying
with all CLIA guidelines. These include:
Wet mounts
Preparations of vaginal, cervical, or skin specimens
All potassium hydroxide preparations
Pinworm examinations
Urine sediment examinations
Fern test
Post-coital direct qualitative examinations of vaginal or
cervical mucosa

• Exempt/wavered tests will be denoted in the remainder of this

handout.

• For complete registration information and current regulations,

please call the CLIA hotline at (410) 290-5850.

III. Simple office laboratory diagnostic tests

A. Gram Stain - Heat fix first! [CLIA waivered]

1. Crystal Violet - 1 min. (I use 5 sec.).
2. Iodine - 1 min. (I use 5 sec.).
3. 95% ETOH - 10-15 sec. (until run-off clear).
4. Safranin - 1 min. (I use 5-20 sec.).
5. After drying, observe at 1000X (condenser up).

B. KOH (5-20% solution ± DMSO ± Chlorazol black or Parker's ink

stains) [CLIA waivered]
1. Scrapings onto slide.
2. Several drops of solution; then coverslip.
3. Heat gently.
4. Scan on 100X (condenser down) and confirm on 450X.

C. Tzanck Prep. [CLIA waivered]

1. Scrape the base of the blister/erosion, almost to the point of
bleeding.
2. Diff-Quik Stain
- Fixative for 10 seconds; rinse
- Diff-Quik I for 10 seconds; rinse
- Diff-Quik n for 10 seconds; rinse
3. Scan with 10X - 45X objective (condensor up)
 4. Observe cells with oil immersion (100X objective)
5. Look for Multinucleated giant cells.

D. Scabies Prep. [CLIA waivered]

1. Superficial epidermal shave (no anesthesia) of burrow or
vesicle, finger webs, ankles/wrists, groin are best locations.
2. Smear material onto glass slide.
3. Several drops of immersion oil on slide, then coverslip (KOH destroys
feces).
4. Observe at 100X power.

E. MoIIuscum Prep. [CLIA waivered]

1. Curette papule.
2. Squash between 2 glass slides.
3. Cover material with few drips of safranin and cover slip.
4. Observe at 100X--look for molluscum bodies (= egg-shaped).

F. Touch Prep. [CLIA waivered]

1. After biopsy, roll specimen on slide (use H&E specimen rather
than culture specimen).
2. Gently heat fix or spray fixative.
3. Stain (Diff-Quik, Wrights, Geimsa, Gram, etc.).
4. Observe.
5. Useful in septic emboli, local infections, leukemia.

G. Fungal Culture - Dermatophytes. [CLIA Non-exemptl

1. DIM (dermatophyte test media).
2. Requires interpretation—many false positives.

IV. Biopsies

A. Shave Biopsy - Use only with superficial pathology.

1. Local anesthesia.
2. Pinch surrounding skin to raise lesion.
3. Shave off with scalpel (#15 blade) - defect should be almost flush with
surrounding skin.
4. Hemostasis - Pressure, aluminum hydroxide or
electrodesiccation.

B. Saucerization Biopsy/Excision.
1. Local anesthesia.
2. Lesion "saucerized" out with lateral and deep margins using scalpel.
3. Base electrodesiccated for hemostasis.
 4. Healing by secondary intention.
5. Post-op: H 2O2 BID, antibiotic ointment (I prefer Polysporin).

C. Punch Biopsy - Sizes = 2inm, 3mm, 3.5mm, 4mm, 5mm, 6mm, 7mm, 8mm,
10mm.
1. Local anesthesia.
2. Stretch skin perpendicular to skin tension lines.
3. Rotate punch back and forth to penetrate dermis.
4. Use forceps (don's use pressure!) or needle to raise lesion, then snip base.

D. Excisional Biopsy with Scalpel - Use with larger and/or deeper (into subcutaneous)
lesions.

E. Incisional Biopsy with Scalpel - Use with large neoplasms that cannot be
easily excised.

F. Helpful Hints.
1. Avoid "too superficial for diagnosis" biopsies.
2. Talk with the pathologist!

G. Hemostasis
1. 10% aluminum chloride in alcohol (Drysol) applied on applicator
swab.
2. Monsel's solution (ferric subsulfate, saturated).
3. Trichloroacetic acid 35-50%.