Approach to dermatologic diagnosis

3/15/14, 10:09

Official reprint from UpToDate www.uptodate.com 2014 UpToDate

Approach to dermatologic diagnosis Authors Beth G Goldstein, MD Adam O Goldstein, MD, MPH Disclosures All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Feb 2014. | This topic last updated: Aug 7, 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?
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Section Editors Robert P Dellavalle, MD, PhD, MSPH Moise L Levy, MD

Deputy Editor Rosamaria Corona, MD, DSc

Approach to dermatologic diagnosis

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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? 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".)

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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). 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

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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): 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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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. Topic 6838 Version 7.0

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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. Graphic 52494 Version 1.0

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Most frequent diagnoses seen by dermatologists and nondermatologists

Condition
Dermatologists Acne vulgaris Dermatitis Actinic keratosis Skin cancer Warts Benign tumors Psoriasis Epidermoid cyst Seborrheic keratosis Tinea infections Nondermatologists Dermatitis Pyoderma Warts Epidermoid cyst Tinea infections Candida Acne vulgaris Dermatosis NOS Skin cancer Benign tumors 14 11 6 5 4 4 3 3 3 3 18 13 12 7 7 6 5 3 3 2

Percent

Data from Fleisher, AB, Feldman, SR, McConnell, RC, Fam Med 1997; 29:648. Graphic 65404 Version 1.0

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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. Graphic 58169 Version 6.0

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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. Graphic 61452 Version 5.0

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Differential diagnosis of macules

Erythematous macules
Drug eruption Viral exanthem Secondary syphilis Rheumatic fever

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

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 Graphic 61066 Version 1.0

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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. Graphic 73398 Version 5.0

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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

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Viral exanthem Xanthoma Graphic 61037 Version 1.0

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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. Graphic 54581 Version 5.0

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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 Graphic 68549 Version 1.0 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.
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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 Graphic 70150 Version 1.0 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. Graphic 68396 Version 3.0

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Telangiectasias

Multiple telangiectasias are present on the nose.

Reproduced with permission from: www.visualdx.com. Copyright Logical Images, Inc. Graphic 71614 Version 4.0

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Pustules in pustular psoriasis

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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 Graphic 56796 Version 1.0

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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. Graphic 81443 Version 4.0

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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 Graphic 78295 Version 1.0 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. Graphic 50151 Version 2.0

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Excoriations

Linear excoriations (secondary to scratching) are present.

Reproduced with permission from: www.visualdx.com. Copyright Logical Images, Inc. Graphic 73387 Version 4.0

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Lichenification

Thickened skin with accentuated skin lines are present in this patient who chronically rubbed and scratched this area.
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Angioedema of the lips

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Scale

Actinic keratosis. Scale overlies erythematous macules.

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Impetigo

Crusted lesions in a patient with impetigo.

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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. Graphic 50615 Version 1.0

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Erosions

Multiple shallow erosions are present in areas of sloughed skin in this patient with toxic epidermal necrolysis.
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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. Graphic 72285 Version 1.0

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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 Graphic 74110 Version 1.0

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.

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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. Graphic 81039 Version 3.0

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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. Graphic 60866 Version 3.0

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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. Graphic 78119 Version 4.0

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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. Graphic 72369 Version 2.0

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Distribution of common skin dermatoses

Flexural distribution
Acanthosis nigricans Atopic dermatitis Bullous pemphigoid

Mouth
Mucous cysts Leukoplakia Fordyce spots Pyogenic granuloma Skin cancers Kaposi's sarcoma

Extensor distribution
Psoriasis Atopic dermatitis (infants) Dermatitis herpetiformis Xanthomas

Axillae
Acanthosis nigricans Hidradenitis suppurativa Impetigo Hailey-Hailey disease Achrocordon Folliculitis Erythrasma Contact dermatitis

Feet/hands
Eczema Tinea infections and "id" reactions Erythema multiforme

Wrists/ankles
Lichen planus Scabies Contact dermatitis Eczema

Buttocks/anal
Folliculitis Psoriasis Hidradenitis suppurativa Lichen sclerosus et atrophicus Streptococcal cellulitis Kawasaki disease

Photodistributed
Lupus erythematosus Photodrug eruption Dermatomyositis Pellagra Porphyria cutanea tarda Polymorphous light eruption

Scalp
Seborrhea Contact dermatitis Tinea capitis and kerion Discoid lupus Psoriasis

Graphic 59080 Version 3.0

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